Document rx4J7n8wOMNgXmzEgKevJJkn0
PAGE 1 OF 2
COMPLEX ENVIRONMENTAL TNfifpENT REPORT
PREPARED BY:
TTfy.A'V
DATE & TIME INCIDENT BEGAN: Jj-ff' % T U ENDED: 44 X ~ K
SPECIFIC LOCATION
------------------------------------- jB
D& c-fc-____ (?SCC
DESCRIPTION OF INCIDENT
__ G-LfZ,LfcQ-
/WH /vf>c> uv
CksA a>-tT Anis^n'tLl . t
jfr*gttr_
,,/* rr. ^
DAY of WEEK m f}/ts A Ay..
SHIFT %
-------- '--------------
0*3 0
J~ZL- JJa'LaJiJ J2sf4-4 Q-i-----------------
8A/2? <?___US/k^rf JriTrtlSm**?.
8^c/< Da
L*x r<?A-~--------
/HAe ,'r*----- kflPf At kt*___ttAUl^J Peafj*
'J '
___ 22___ irt A,
i G&jZftP
WAS THERE A RELEASE?
CSHflMHI ft>c ffo~n __________ __________ __________ __________ __________
________
TOTAL
QONCflilBAUflH
____d________
_______________ _______________
__________________
Q.UANXITY
S~ lbs
LBS LBS LBS _________ LBS _________ LBS LBS
.<"" LBS
PHYSICAL STATE
t &_______
________________ ________________ ________________ _____________ __ _______________ _ _____
__
AIR/CROUND/WATER
_ uSArtfl' _
___________________
___________________ ___________________ ___________________
IF VC RELEASE, WAS IT BY MONITOR OR LEAK PATROL? DID ANY OF THE RELEASED SUBSTANCES MIGRATE OFF-SITE7
u&i
IF YES:
COMPONENT gtf.egEaa*
Q.VAHIUX
.<r
LBS LBS LBS LBS US
LsATB^
PRIMARY CAUSE CODE: , 0 People Error (PE)
Qlntarnal Corrosion (IC) Mechanical Problem (MP)
Instrument Problem (IP)
8External Corrosion (EC) QOther Problem (OP)
DESCRIPTION/SOURCE, CAUSE & DURATION
S(?At-l#A
X7^ / f<=> s s/ Xly fcu
tfrtTe ft
T aAs
Af* y/"
A- h L<2.___P/7--c2*i- a Ft.--s^b,--.5<?- 7 B&T*-
SL 089779
CflmSX ENVIRONMENTAL INCIDENT .REPORT
PAGE 2 OF 2
VEATHER CONDITIONS (Circle One)u
LEAR
WIND SPEED & DIRECTION /OjA mph /i/fr
PARTLY CLOUDY
CLOUDY
RAIN
TEMPERATURE M *F HUMIDITY /;//?. %
DATE CLEANUP BEGAN
COMPLETED
EXPECTED TO BE COMPLETED
J~i A x. .ACTIONS TAKEN TO MINIMIZE OR CONTAIN THE RELEASE $T2)A?0*<L ^ ^
cL
DESCRIBE CLEANUP ACTIONS
f/c
u iStfr- Jffl &y
DESCRIBE RELEASE PREVENTION PRACTICES AND POLICIES UTILIZED WHEN THE RELEASE OCCURRED
(BACKUP SYSTEMS, CONTAINMENT SYSTEMS, TRAINING PROGRAMS, ETC.)
l----------
t--, D u & T>
asMA-ft/C/ A J
WHICH ABOVE PREVENTION PRACTICE OR POLICY, IF ANY, WERE INEFFECTIVE IN PREVENTING THE
RELEASE
:*A 7*
L&<J4?L
*/*&**A*-------
NOTIFICATIONS (Who & When)
NAME
SHIFT SUPERINTENDENT
D.
_________
ENVIRONMENTAL
HI, fluhaz^____________
OTHER
C, Pf/zn*, m. usoaJL
DATE & TIME fa 4
% l `Very- - - --....
- ___________
1. Attach action plana to prevent recurrence and/or followup plana to final copy, 2. Attach releaae calculations to final copy, including calculations for off-sice
migration.
FOR ENVIRONMENTAL USE ONLY NOTIFICATIONS MADE (Agency, Name, Time): REASON REPORTED/NOT REPORTED _______________ OTHER COMMENTS ___________________________________
SL 089780