FORM C
SITE CLEAN-UP/REMEDIATION ASSESSMENT REPORT (FORM C)
Company Name
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Date of Assessment
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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Hour
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Minutes
AM
PM
AM/PM Option
Site Name
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OML
*
Date/Time of Incident
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Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
1
2
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Hour
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10
20
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50
Minutes
AM
PM
AM/PM Option
Area and Depth of Impact
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GPS FIELD POINTS
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Total Length in meters
Length Surveyed in meters
Differential GPS
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Yes
No
Spill Start Point GPS
*
Total Length in meters
Length Surveyed in meters
Spill End Point GPS
*
Total Length in meters
Length Surveyed in meters
Contaminated Media
*
Vegetation
Soil
Type option 4
Sediment
Inland Surface Water
Brackish Swamp Surface Water
Off shore Surface Water
Underground Water
Other
Date Clean‐up Programme Comenced
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
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8
9
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11
12
:
Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Method of Clean‐Up
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Low Pressure Wash
Mannual
Mechanical
Surface Wash
Sorbents
Chemical Disparsant
Vacuum Skimming
Other
Estimated quantity of oil / containment recovered
*
Method of Debris Disposal
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Controled Inciniration
Buried in lined pit
Chemical Treatment
Sanitary Landfill
Land farming
Other
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Site Visual Observation
Nature of Soil
*
Show Heavy Impact
Medium Impact
Minimal Impact
Other
Nature of Surface Water
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Oil Sheen Present
No Oil Sheen Present
Other
Nature of Vegetation
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Withered
Withering
Luxuriant
Site Photos
*
Yes
No
Date Site clean‐up ended
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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
Sample collected after the clean‐up program
*
Soil
Sediment
Water
Other
Result of Laboratory Analysis of Samples collected Pre/Post Remediation
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Rows
Sample
Test Method
Result
Result
Parameter
TPH
BTEX
Trace Metals
Arsenic
Barium
Cadmium
Chromium
Copper
Mercury
Lead
Nickel
Zinc
Total Dissolved
Total suspended Solids
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