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.
Type of Report:
Initial
Progress
Final
Division Where Incident Occurred
Construction
Trucking
Shop
Materials
East Trucking
Ft. Berthold
South Texas
West Texas
New Mexico
IHD Liquids
WDW
Location Name & Number:
Report Date:
-
Month
-
Day
Year
Date
Client Name
Client Contact
First Name
Last Name
Date Spill Discovered:
-
Month
-
Day
Year
Date
Time:
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date of Clean Up:
-
Month
-
Day
Year
Date
Foreman Name:
First Name
Last Name
Foreman Email:
example@example.com
Project Name:
Where did the spill occur
Client Name:
Did the spill occur client project?
Client Contact:
First Name
Last Name
Person Completing Report:
First Name
Last Name
County:
State:
Location- use a dash "-" for blank fields(save when done)
GPS Location will automatically populate, or drag pin to actual location (use two fingers to zoom for more accurate location):
1. Type of Material Spilled:
Bbls Spilled, or
Gallons Spilled
Amount Recovered
Oil
Water
Condensate
Other
Total
2. Cause of Spill:
3. Waterways:
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"):
Yes
No
State Oil & Gas Commission informed
NRC Informed
EPA Informed
RRC Informed
Ticket Number:
TRC, EPA etc..
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
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20. Foreman Signature:
21. Office Signature
Submit
Should be Empty: