Weston Environmental Effluent

Affairs

Confidential For Internal Company Use Only

Limitations
Pollution
Abatement

Spill

ENVIRONMENTAL INCIDENT REPORT

Procedures

Waste
Air,

Management

Odour

Waste

Emission

Reduction

Form Last Revised: October 30, 2007

PART A
Facility name
Address of facility
Manager in charge at

Date incident was reported to

time of incident
Incident reported by whom

Manager in charge
Incident reported to

Date of incident (Y/M/D)

Exact location of incident (e.g., exact address,

Time of incident (indicate a.m. / p.m.)

intersection)
Weather conditions at time of incident (e.g., fog,
dry, raining/snowing, snow covered, windy)
Incident description (include spills, neighborhood
complaints, leaks, investigations, notices of
violations)
Name of material released and characteristics (e.g., solid, liquid, gas)
WHMIS/HAZCOM/Hazardous Substance Registration (MSDS sheets)
Quantity released including units of measure (e.g., litres, gallons etc.)
Medium affected by release (e.g. land, air, water)
Extent Of Spill (e.g. storm sewer, sanitary sewer, ditch, creek,
evaporation to air)
Did an evacuation occur?
Yes
No
If yes, provide details
Property/Equipment involved (attach a drawing or photo if necessary)
Was the incident caused by a third-party
Yes No
If yes, provide name
(e.g., ingredient or fuel supplier)?

of third-party

Date and time Provincial Environment Agency/State Environment

Department Agency was notified:
Name and phone number of Responding Environmental Officer

Date

Tim
e

Weston Environmental Effluent

Affairs

Confidential For Internal Company Use Only

Limitations
Pollution
Abatement

Spill

ENVIRONMENTAL INCIDENT REPORT

Procedures

Form Last Revised: October 30, 2007

Waste
Air,

Management

Odour

Waste

Emission

Reduction

PART B
What actions were taken to react to the incident (eg. spill
clean-up, plug & dike)?
Was a third-party notified to

Yes

No

If yes, provide name

respond to the incident?

of third-party
What further actions are being taken in regards to the incident
(eg. absorbent properly disposed, soil remediation)?
Description of where the material removed will be disposed:
Was there hazardous waste

Yes

No

generated by the incident?

If yes, provide / attach details on

disposal (e.g., manifests, invoices)

Reason (CHECK ONE ONLY)

R1 Equipment

R2
Huma
n
Error

R3 Process Upset

R4 Container Failure

R5 Vehicle Leak
R6 Refrigeration Leak

In Canada all refrigerant purchases must be approved by Plant Manager and

Corporate Engineer. Incident Reports involving refrigeration must be
accompanied by a copy of the purchased refrigeration invoice.

R7 Notice of Violation
R8 Other (Specify) (e.g. Not Company Owned
Vehicle, or Outside Supplier/ Contractor)
Costs Associated with Incident
Materials Lost
Name

Amount (Specify units)

Cost

Amount (Specify units)

Cost

Clean-Up
Description
Lost Productivity
Employee Hours
Other (specify) (e.g. waste disposal)
Description

Total Costs
Manager Responsible
To Take Action
Investigated By
(print)
SIGNATURE (Manager)

Planned
Completion Date
Phone No.

Actual
Completion Date
Date Of
Investigation

SIGNATURE (Supervisor)
COPIES: 1. Facility central environmental file 2. Environmental Affairs

Approval Signatures:
V.P./Director/G.M

Environmental Affairs

Weston Environmental Effluent

Affairs

Confidential For Internal Company Use Only

Limitations
Pollution
Abatement

Spill

ENVIRONMENTAL INCIDENT REPORT

Procedures

Waste
Air,

Management

Odour

Waste

Emission

Reduction

(required when incident is reported to any Government Agency)

Form Last Revised: October 30, 2007