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 of 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