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Incident Date:Incident Time: <br />Did incident occur off UPS property? <br />Submitted By:Email ID:Dept:Phone: <br />Incident Information <br />Contact Information <br />Mgr in Charge:Email ID:Dept:Phone: <br />Incident Product Related Information <br />Product Involved: Other Product: <br />Ingredients: Reportable Quantity: <br />Shipper: <br />Consignee:Package Tracking #: <br />Shipper #: <br />Source:Other Source: <br />Cause:Quantity Spilled: <br />Type of surface where spill occured:Paved / Unpaved <br />Was product contained to UPS Facility, Property, or Vehicle ?Yes / No <br />Did product enter sewers, pipes, ditches or a body of water ? <br />Was the facility evacuated ? <br /> <br />Yes / No <br />Did spill result in a closure of a public roadway ?Yes / No <br />Did the media (any form) learn of the spill and respond to the scene ?Yes / No <br />Organization(s): <br />Regulatory Authorities Notified <br />Local Agency: Contact Name:Phone:Time: <br />State Agency:Contact Name:Phone:Time: <br />Fed. Agency:Contact Name:Phone:Time: <br />Fed. Agency Incident #: <br />Region:District: <br />Facility: <br />Address: <br />Location of Incident <br />Yes No <br />Status:Open / Closed <br />Oil Spill/Hazardous Substance Incident Report <br />Page ofUPS Confidential 1 2 <br />Did spill result in any damages or injuries ? Yes / No (If Yes, please explain on next page under Description of Incident)