Spill Notification Form
Veracity Field Services
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
Type of Report
Initial
In Progress
Final
Operation Where Incident Occurred
Construction
Drilling
Completions
Production
Water
Midstream
Site/ Lease Name
Location Coordinates
Person Reporting Spill
First Name
Last Name
Email
example@example.com
Type of Product Spilled
Produced Water
Gasoline or Diesel Fuel
Crude Oil
Chemicals
Lubricant Oils
Other
Measurement Type
Gallons
Barrels (Bbls)
Amount of Product Spilled
Total gallons divided by 42
Amount of Product Recovered
Total gallons divided by 42
If Spill in Excess of 5 Bbls was TRRC Informed
N/A
Yes
No
Use H-8 for for notification of TRRC
Upload TRRC H-8 Form
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of
Date of Clean Up
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What Happened
Did Spill Enter Waterway?
Yes
No
Name of Waterway
Was There Crop Damage?
Yes
No
Was Land Owner Informed?
N/A
Yes
No
Landowner Contacted
Estimated Damage Cost
Size of Area Affected by Spill
Estimated Cost of Cleanup:
Investigation
Investigation Leader
First Name
Last Name
Investigation Team
Name of Event
eg: oil spill; chemical spill; produced water spill
Causal Chart
Root Cause(s)
Corrective Action Items
Signature
Submit
Should be Empty: