Document mpNgjOGEwKD3wKXrBpeDoZXb0
jjas.te Xreatjnent, Unit Spills and Release? Report
Items 1-14 to be compl ted by the lead operator
1. PattJ _____________
2. Tjjng oi Day:
3. Unit: (Check all that apply)
____ WTU STRIPPERS ___ BOTTOMS PLANT ___ SLUDGE KETTLE ____ P/T STRIPPERS
____ CSS ___ TETRA ____ CPC ___ BAT
____ FORMATE ____ INCINERATORS ____ WASTE CLASSIFIERS ____ OTHER (Describe below
4. Description at Event: (Describe etails of where and why the leak occurred)
5. MfrLtfial Spilled: (Describe the stream and composition of spill)
6. Physical State: (Check all that apply)
_____ Solid
Liquid
Vapor _ Boiling Liquid
7. Amount Spilled: (Estimate or calculate the quantity to the best o your knowledge; ex. 1/4 gallon, 1 pint, etc.)
8. Whfirt did spill S to?: (Check all that apply)
--in Ground Air Roadway Ditch
------- Process Sewer _____ Storm Sewer
Concrete Containment
Other (Describe)
9* Classification
Release: (Check the yellow book to find this out and check the appropriate classif.)
------- Unit Release
_____ IRQ
_____ irqc
_____ Agency Reportable
10. N_q.tiiication: (Based on the classification of the release, is it necessary to notify supervision?)
_____ Yes
No (Unit release)
If No, your completion of this report is sufficient
If Yes, who was notified? _ Time_
.11 Irngdiala SPJLrqg.tiyq Action Taken: (Describe below)
.12 Shift Discussion
Yes No
If no, explain why.
13. Re.cgmm pdatigng fxpm aeejratprg t prevent reoccurance
hi
fc.C!
MJ
*
S'
14. Lead Operator''* Nsmo-
SL 002058
ftw O
It ms 15 - 18 are th responsibility of th unit sup rvisors to compl te.
15. %gs;p,oagibi$ supervisor's name
16. Determine Root Cause of Spill: (Check one that best applies)
Mechanical Seal Leak _____ Mechanical Problem
________ Internal Corrosion ___ External Corrosion
Instrument Problem
_____ Design Problem
People Errors (see list below)
Circle one that best applies, for people errors only 1. Failure to follow procedures. 2. Design Problems 3. Lack of Training for routine operations 4. Inadequate crisis response. 5. Lack of experience or planning. 6. Failure to communicate properly. 7. Complexity of instrument systems. 8. Others (give details)
Others (give details below)
17. List corrective measures_to prevent this f_rom haBBSfllflfl Sflaia and IftEflgt sflmBl-a&ian dalag-u
18. Note data whsa all qgrxostiy? msagarag aca carnal ad and Ihia. i&lsags Is. sloaad out.
date
initials
SL 002059
CONFIDENTIAL* Subject to Protective Order
of 14f .Indicia 1 District Cotift No. 91-1145
R lease No:
Wi'l ^ ^ 4ir *
* / n/ OT.TD