Spill Report Form

Spill Report Form
Please report all Spills to the Spill and Incident Number

306-460-0179
Your Name*

First NameLast Name
Date of Spill*

MonthDayYear
Date
Time of Incident Reporting*

:HourMinutesAM/PM Option
Division*

AbandonmentCompletionsConstructionDrillingOperations
Operations Area*

AB - OperationsChauvin - OperationsSK - Operations - Avon Hill - Scott OsterholdSK - Operations - Coleville - Chris SolomonSK - Operations - Dodsland - Cory TurkSK - Operations - Hoosier - Trent MartinSK - Operations - Maintenance - James ElliottSK - Operations - Plato - Tyler Reid
Completions Area*

AB - CompletionsAB - Well ServicingSK - CompletionsSK - Well Servicing
Construction Area*

AB - ConstructionSK - Construction
Abandonment Area*

AB - AbandonmentSK - Abandonment
Drilling Area*

AB - DrillingSK - Drilling
Surface Location*
Downhole Location (if applicable)
Information
Estimated Time of Spill*

:HourMinutes
to
until :HourMinutes
Activity at time of spill*

Abandonment and ReclamationDrilling and CompletionsConstructionGeoPhysicalOperationsOther
Facility Type ( You must include picture of Facility Sign)*

WellSingle Well BatteryMulti Well BatterySatellite BuildingPipeline HeaderFlowlineOther
Facility Sign Photo

Take Picture / Upload Photo

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Description of Spill including Pictures (Who, What, When, Where and Why)*
Pictures of Spill*

Take Picture / Upload Photo

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Was a 3rd party responsible for Spill*

YesNo
Vendor Name
Persons Notified*

HSEForemanLead Operator
Cause Of Spill (If other, please enter description)*

Tank FailureWellhead PipingPipeline Failure (include to/from location of line)TruckingEquipment FailureLine StrikeVandalismOther
Is spill On Lease or Off Lease (If off lease land owner must be contacted)

On LeaseOff LeaseUndetermined
Landowner Name
Landowner Phone Number
Date Contacted

MonthDayYear
Date
Is spill volume greater than 2m3?*

YesNo
Spill Volume (m3)*
Spill Substance(If other please include picture of Spilled substance Container or MSDS)*

Produced OilProduced H2OEmulsion (enter BS&W in comments)Other Substance
BS&W*
Picture of SDS Label

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Is spill contained(How and Where)*

YesNo
Has Cleanup begun?*

YesNo
Describe work being done and by whom*
Is clean-up complete at time of reporting?*

YesNo
Pictures of site after cleanup*

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Is leak detection or monitoring system on site?*

YesNo
System on site*

TokuDV8WatchdogSCADAMetrotank
Was a leak detection or monitoring system used to identify spill?*

YesNo
Should be Empty:

Spill Report Form

Information