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YRC, INC. Complete ASAP and Fax immediately to <br /> • SAFETY ENVIRONMENTAL SERVICES Ruben Byerley, KCGO: (913) 266-4031 <br /> Petroleum Product Discharge Reporting Form <br /> I. Date of Incident: 2. Time of Incident: AM or PM <br /> 3• Date of Reporting: 4. Time of Reporting: AM or PM <br /> 5. Terminal Reporting: 6• Phone#(w/Ext.): <br /> 7. Reported by(Name): <br /> 8. Amount of Product Released: <br /> 9• Exact Spill Location: <br /> 10. Amount of Product Recovered to Date: <br /> 11. Type of substance discharged: <br /> ❑ Diesel Fuel ❑ Gear Oil ❑ Heating Oil <br /> ❑ Motor Oil ❑ Waste Oil ❑ Other-Describe: <br /> ❑ Antifreeze ❑ Junk Oil <br /> 12. Cause of Release (check all that apply) <br /> ❑ Overfill ❑ Puncture ❑ Corrosion <br /> ❑ Loose Connection ❑ Tank leak ❑ Fire/Explosion <br /> ❑ Spill ❑ Vehicle Accident ❑ Human Error <br /> ❑ Other: <br /> 13. Mode of Release (check all that apply) <br /> ❑ Dispenser ❑ Fitting ❑ Tank Truck <br /> ❑ Tank ❑ Valve Failure ❑ Truck Saddle Tanks <br /> ❑ Fill Pipe ❑ Pipeline ❑ Drum <br /> ❑ Other: <br /> 14. Method of Discovery <br /> ❑ Leak Detector ❑ Vapor or Visible signs of a discharge in the vicinity <br /> ❑ Inventory Control ❑ Emptying and/or Inspection <br /> ❑ Monitor Wells ❑ Free Product in surface water <br /> ❑ Other: <br /> 15. Discharge Affected: (check all that apply) <br /> ❑ Soil ❑ On Property ❑ Surface Water <br /> ❑ Sanitary Drain ❑ Off Property ❑ Other-Describe: <br /> ❑ Storm Drain ❑ Drainage Ditch <br /> 16. Details of Incident: <br /> 17. Corrective actions taken in response to the discharge: <br /> 18. Agencies Notified: <br /> ❑ Fire Department(Phone# ) ❑ YFS Environmental Services,KCGO <br /> ❑ Local Agency(Speck and give phone#): <br /> ❑ Other: <br /> A-7 <br />