DENR Spill or Release Report

In compliance with the Environmental Policy for Aircrafts in Bermuda, all spills or leakages of one US gallon or more must be reported as soon as practicable and within four hours. By completing the following form the responsible party will be providing all the relevant information regarding the incident. An email will then be submitted automatically via this system to the Department of Environment and Natural Resources with the spill notification.

Date/Time 

NAME AND TITLE OF PERSON SUBMITTING WRITTEN REPORT

TELEPHONE NUMBER

EMAIL ADDRESS

NAME OF BUSINESS

ADDRESS

BUSINESS TELEPHONE NUMBER

RELEASE LOCATION (provide address if different than business, if known, and give directions to the spill location. Include nearest highway, town, road intersection, etc.)

SITE IDENTIFICATION NUMBER AND OTHER IDENTIFYING NUMBERS (if applicable)

RELEASE DATA. Complete all applicable categories. Check all the boxes that apply to the release.
Provide the best available information regarding the release and its impacts.

DATE & TIME OF RELEASE
(if known)

DATE & TIME OF DISCOVERY

DURATION OF RELEASE (if known)
days  hours  minutes

TYPE OF INCIDENT
 Explosion
Fire
Leaking container
Loading/unloading release
Pipe/valve leak or rupture
Vehicle accident
Other

MATERIAL RELEASED (Chemical / fuel or trade name)

CAS NUMBER or HAZARDOUS WASTE CODE

ESTIMATED QUANTITY RELEASED (indicate units)

PHYSICAL STATE RELEASED (indicate if solid, liquid, or gas)

FACTORS CONTRIBUTING TO RELEASE
 Equipment failure
Operator error
Faulty process design
Training deficiencies
Unusual weather conditions
Other

SOURCE OF LOSS
 Container
Truck
Fuel Truck
Tank
Pipeline
Ship
Tanker
Other

TYPE OF MATERIAL RELEASED (Provide name of product if known)
Agricultural: manure, pesticide, fertilizer
Hazardous waste
Liquid industrial waste
Oil/petroleum products or waste
Salt
Sewage
Other
Unknown

IMMEDIATE ACTIONS TAKEN
 Containment
Diversion of release to treatment
Dilution
Evacuation
Decontamination of Hazard
Removal of persons or equipment
Neutralization
Monitoring
System shut down
Other

RELEASE REACHED
 Surface waters (include name affected resource)

Distance from spill location to surface water, in feet

Drain connected to sanitary sewer (include location of drains)

Drain connected to storm sewer (include name of drain or water body it discharges into, if known)

Soils (include type e.g. clay, sand, loam, etc.)

Ambient Air

Spill contained on impervious surface

EXTENT OF INJURIES, IF ANY

WAS ANYONE HOSPITALIZED?
Yes  No

NUMBER HOSPITALIZED

TOTAL NUMBER OF INJURIES TREATED ON-SITE

DESCRIBE THE INCIDENT, THE TYPE OF EQUIPMENT INVOLVED IN THE RELEASE, HOW THE VOLUME OF LOSS WAS DETERMINED, ALONG WITH ANY RESULTING ENVIRONMENTAL DAMAGE CAUSED BY THE RELEASE. IDENTIFY WHO IMMEDIATELY RESPONDED TO THE INCIDENT (own employees or contractor — include cleanup company name, contact person, and telephone number).  ALSO IDENTIFY WHO DID FURTHER CLEANUP ACTIVITIES, IF PERFORMED OR KNOWN WHEN REPORT SUBMITTED

ESTIMATED QUANTITY OF ANY RECOVERED MATERIALS AND A DESCRIPTION OF HOW THOSE MATERIALS WERE MANAGED (include disposal method if  applicable)

ASSESSMENT OF ACTUAL OR POTENTIAL HAZARDS TO HUMAN HEALTH (include known acute or immediate and chronic or delayed effects, and where appropriate, advice regarding medical attention necessary for exposed individuals.)

BERMUDA AUTHORITIES NOTIFICATIONS
INITIAL CONTACT BY
Telephone  Fax  Email  Other

OTHER ENTITIES NOTIFIED
PERSON CONTACTED & PHONE NUMBER