Fillable Blank Spill Form Template Fillable 3-5-20

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Blank Spill Form Template Fillable 3-5-20

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Spill Notification Form
Department of Safety and Environmental Management
Created: 5/6/2019
Revision: New 1 | Page
The purpose of this form is to provide A DETAILED DESCRIPTION the cause of the spill, including a
thorough explanation of the task(s) being performed, identification of the root cause, and the appropriate
corrective actions. This form is to be completed and emailed to
safety.environmental@bangormaine.gov
within 24 hours of the spill by the department responsible for the spill.
1. For ALL spills, person completing the spill form
WILL notify the City Safety and Environmental
Management Office as follows: Ryan Kuhl, Call IMMEDIATELY: 207-812-8922, email form to
safety.environmental@bangormaine.gov
2. IF UNABLE TO REACH, CALL Debbie Laurie, Finance Director, 207-735-5037
3. For spills over 10 gallons, if unable to reach Ryan or Debbie, CONTACT MAINE DEP: 1-888-769-1137
Prepared by:
Date of Spill:
Department:
Time of Spill:
Supervisor:
Is spill contained? Yes No
Material Spilled:
Quantity Spilled:
Weather:
Spilled to Waterway:
Spilled to Soil:
Spilled to Impervious surface:
Description of the Incident (Cause/Location of Spill/Vehicle or Equipment #/Aircraft #/Tools being
used:
Cleanup Details: (Quantify amount of waste generated, materials used, resources required)
Did the spill occur during a normal part of your job? Yes No
If no, please describe:
What can be done to prevent this from happening again?
DEP Spill Number:
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Blank Spill Form Template Fillable 3-5-20

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Completed 11 July 2020

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