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A RACn CDII I 0PPn12T <br /> <br />• <br />• <br />Person Reporting Phone <br /> <br />Responsible Party (Company) Department/Division <br /> <br />Date/Time Occurred'( Weather Date/Time Reported <br /> <br />Product Spilled if mixture, describe percentag e) <br /> <br />Quantity Spilled Surface T p e (road/pad) Surface Area (ft) " <br /> <br />Describe Spill as: <br />o Off Pad/Road <br />o Into Building/Structure <br />o Into Secondary Containment Volume Activity During Spill <br />o Construction <br />o GW Monitoring <br />o Equip Fueling/Maintenance <br />o Drilling <br />o Road Travel <br />o Well Work <br /> o Hydrology Testing o Unknown <br />Source of Spill - Root Cause <br />o Truck-mounted Tank <br />o ABS Tank/Pit <br />o Drums/Containers <br />o Pipeline/Hose <br />o Fittings/Seals/Connections <br />o Pump <br />o Unknown <br />o Other: o Procedures <br />o Training <br />o Quality Control <br />o Communication <br />o Equipment Malfunction <br />o Management <br />o Unknown <br />o Other: <br />Detailed Explanation of Root Cause <br /> <br />Corrective Action <br /> <br />Response and Cleanup "Actions <br /> <br />Disposal Facility/Disposal` Method Quanitity`Contained/RecoverdlDisposed <br /> <br />Date of Final Cleanup Date "of Final Disposal <br />Title ` Date Time Person Called/Left Message <br />Company Supervisor <br />AMSO Site Supervisor <br />AMSO Project Mgr. <br />Signature of AMS©Site Supervisor Date <br />Gr+arnal Nntifira#inn <br />Agency Contacted Date/Time of Verbal Report Date of Written Report