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2 . 4 . 2 Spill Report Form <br /> -mill I <br /> Issue Date : dune 2010 Review Frequency: Annually Issued 6y: EHS&S Dept. Supersedes 2104 <br /> 1 . Person completing form: Phone: <br /> 2 . Facility: <br /> Ilk I <br /> Name Location <br /> 3 . Type of incident: ( check all that apply) Liquid Dry <br /> Li Fertilizer Release <br /> 13 Hazardous 0 GasiDiesel <br /> Q Nonhazardous © Oil release <br /> Q Pesticide to Complaint from neighbor or public <br /> Q Hazardous U Other: <br /> Li Non- hazardous <br /> 4 . Date of Incident , Inspection or Complaint: Time: <br /> 6 . Substance( s) Released : <br /> 6 . Amount Released : Units (lbs, gallons) <br /> 7. Exact Location of Spill : <br /> Be Weather Conditions <br /> 9 . If the incident was a spill, did it reach: (check all that apply) <br /> Paved surface , contained & cleaned up Soil, adjacent to property <br /> Soil contamination , on site only Surface water <br /> Storm drain Ground water <br /> Sanitary drain Other (describe on back) <br /> 10 . Cause of incident or reason for inspection/complaint: <br /> 11 . If a chemical release incident, it was reported to <br /> IMMEDIATELY (WITI [ IN ISM INUTES) REPORT SPILLS OR RELEASES EXCEEDING RQ TO T €€E <br /> NA:1 ' €C) AI. RESPONSE CENTER $ 00424 " 02 <br /> Date/Time Reported Name of Individual Reported to <br /> Location Supervisor <br /> AOM <br /> EH& S Mgr, <br /> National Emergency Response Center Deport Number: <br /> State Emergency Response Center <br /> Local Emergency Response Center <br /> State Environmental Agency <br /> Local Fire Department <br /> Other (Describe on back of page) <br /> 12 . Ramediai Action Taken or inspector' s Findings : (describe) <br /> 13. Steps Taken (or proposed) to Prevent Reoccurrence : <br /> Submit to Environmental, Health: & Safety Manager as soon as possible following the incident <br /> Signed [nate <br />