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RYDER Report Of Significant* Environmental Incident '(Over 25 gal lone of hazardous or regufated substance released onto land and not threatening water,any amount of hazardous or regulated substance released into water(steam, lake) or a storm or sewer drain;or any public agency involvement.) TYPE OF INCIDENT(CHECK ALL THAT APPLY): DATE& TIME OF INCIDENT ❑ VEHfCLE ACCIDENT ❑ SUBSURFACE RELEASE ❑ SURFACE SPILL ❑ RELEASE TO SEWER I❑ RELEASE TO WATER ❑ RELEASE TO AIR [] OTHER RYDER COMPANY NAME DISTRICTIOPERATING AREA(QA)NAME{Name In which the release occurred.) DISTRICTIOA CODEJ LOCATION CODE STREET ADDRESS CITY STATE ZIP CODE TYPE OF MATERIAL INVOLVED EST. OF AMT. OF MATERIAL RELEASED EST, OF AMOUNT RECOVERED SITEIAREA WHERE INCIDENT OCCURRED .BE SPECIFIC{ADDRESS, IF POSSIBLE,OR AT LEAST CJTYlTOWN AND STAT€,LOCATION CODE, IF APPLICABLE) DESCRIPTION OF INCIDENT(BE SPECIFIC) ENVIRONMENTAL COORDINATOR'S, NAME,TITLE AND DATE INCIDENT REPORTED TO ENVIRONMENTAL SERVICES-MIAMI WAS"SPILL CENTER' NOTIFIED? ❑YES ONO EMERGENCY COORDINATOR'S NAME,TETLE,DATEITIME INCIDENT REPORTED TO ENVIRONMENTAL COORDINATOR ESTIMATED COST OF CLEAN-UP VEHICLE INFORMATION TRUCK LICENSE NUMBER I RYDER UNIT NUMBER UNIT'S DOM. LOC.CODE TRAILERFYANKER LICENSE NUMBER TRAILERrrANKER UNIT NUMBER DRIVER'S NAME INSURANCE 0 UNIT - PROVIDED BY []RYDER ❑CUSTOMER COVERAGE ON: O TRAILER PROVIDED BY (]RYO£R ❑CUSTOMER NAMES OF PUBLIC EMERGENCY SERVICES DATE& INDIVIDUAL'S NAME,TITLE&PHONE NO. INCIDENT ANDIOR PUBLIC AGENCIES CONTACTED TIME )REPORT NO. NAME OF PRIVATE EMERGENCY RESPONSE DATE& INDIVIDUAL'S NAME,TITLE&PHONE NO. INCIDENT COMPANY INVOLVED TIME REPORT NO. MPANY NAME, ONE NUIMER� NAME(S) OF INDIVIDUAL(S) INVOLVED IN INCIDENT AND COMMENTS FROM FINDIVDUAB(S REPORT PREPARED BY-NAME PREPARED REPORT APPROVED BY -NAME CLEAN UP ACTION AUTHORIZED BY -NAME SIGNATURE SIGNATURE SIGNATURE STREET ADDRESS CITY STATE ZIP CODE 1TELEPHONE NUMBER l RECOMMENDATION TO AVOID RECURRENCE IBE SPECIFIC)