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IN CASE OF EMERGENCY CALL:911 COMPLETE IN FULL AFTER CLEANING THE SPILL. <br /> CHEMICAL SPILL RESPONSE <br /> LOCATION of Spill: Maintenance Shop <br /> WHAT was spilled?: N OIL - ❑HYD. FLUID - ❑GAS - ❑ DIESEL - ❑OTHER: <br /> HOW MUCH was spilled?: X < 1 GAL- ❑< 5 GAL - *❑OTHER: <br /> Is anyone INJURED?: ❑ Yes X No Supervisor Notified?: N Yes ❑No <br /> Medium Spilled: Indoors or Outdoors? <br /> INDOOR Floor: ❑Cement - ❑Other: <br /> **Water: El Drain - ❑Sewer- N N/A <br /> OUTDOOR Ground: N Paved - []Dirt - ❑Gravel <br /> Person in charge of area: John Doe <br /> I <br /> Cause of Spill: Leaking Forklift <br /> G ° 21 <br /> SDS available? ® Yes <br /> -IN <br /> Chemical Inventory Available? a_ X Yes ❑No <br /> Electrical/Fire Hazard N Yes ❑No <br /> Skin Absorption Hazard N Yes ❑No <br /> Other Specify: <br /> Are ADJACENT AREAS affected? ❑ Yes N No <br /> Is area BARRICADED / secured? ❑ Yes ❑No N N/A <br /> Person Responsible for Spill <br /> Name : Jane Do Title: Employee <br /> Others Involved/Witnesses: Jim Doh <br /> Spill Cleaned: N Yes ❑No <br /> Medium used to Clean: N Sorbent El-Blankets - ❑Socks - ❑Pillows <br /> Used Medium placed in Chemical Storage and Covered: X Yes ❑No <br /> Person Who Reported Spill <br /> Name : Jane Do Title: Employee <br /> Signature: X Date: 1/10/0000 <br /> * In the event of a large uncontrolled spill refer to the Consolidated Emergency Response Plan. <br /> **In the event of spill/discharge into water or sewer contact the Port of Stockton- (209) 946-0426. <br />