Spill Report
NOTE: In completing the form it is important to report only the facts. This is especially important with respect to items #2, #9 and additional remarks.
NOTE: In completing the form it is important to report only the facts.This is especially important with respect to items #2, #9 and additional remarks.
Type of Report:
Initial
Progress
Final
Type of Spill:
Non-Recordable
Recordable
Information Only
Operational Group:
Drilling
Completions
Construction
Other Party Spill
Initial Report Date:
-
Day
-
Month
Year
Date
Date Spill Discovered:
-
Day
-
Month
Year
Date
Time:
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Date of Clean Up:
-
Month
-
Day
Year
Date
Report Closed:
Yes
No
Supervisor Name:
First Name
Last Name
Supervisor Email:
example@example.com
Location Name:
Where did the spill occur
Person Completing Report:
First Name
Last Name
Region:
Texas
Location (save when done):
1. Type of Material Spilled:
Rows
Bbls Spilled, or
Liters Spilled
Amount Recovered
Oil
Diesel
Condensate
Chemical
Water
Lubricating Oil
Other Product Spilled
2. Cause of Spill/Notes:
3. Waterways:
Rows
Yes
No
Waterway/s nearby?
Did spill enter waterway?
4. Name of waterway/s (save when done):
5. How was spill contained:
6. Are there any crops being grown on land where spill occurred:
Yes
No
7. Type of Crop:
8. Type of Ground:
Dryland
Irrigated
Pasture
Lease
9. Extent of Damages:
Attach map if necessary
10. Area Affected- use a dash "-" for empty fields (save when done):
11. Estimated Cost of Cleanup:
12. Landowner Informed:
Yes
No
13. Landowner Contacted (save when done):
14. Notifications Made (use "X"):
Rows
Yes
No
MME Commissioner
MME Chief Inspector
Third Party (Environmental Firm)
Other Party Notification
Notification Entity Close-Out Report Submitted:
Yes
No
N/A
MME Ticket Number:
15. Person Contacted (save when done):
16. Did any regulatory official inspect spill or help clean up:
Yes
No
N/A
17. Person Contacted (save when done):
18. Clean up action taken:
19. Additional Remarks:
Upload File:
Browse Files
Cancel
of
Order of Events
Investigation
Investigation Leader
First Name
Last Name
Investigation Team
Name of Event
Causal Chart
Root Cause(s)
Corrective Action Item(s)
20. Supervisor Signature:
21. Office Signature
Submit
Should be Empty: