Spill Reporting Information Form - Template



|Insert Company’s own logo or name |

SPILL REPORTING INFORMATION FORM (template)

Provincial Emergency Program (PEP): 1-800-663-3456

This template is based on the reporting information required under the B.C. Spill Reporting Regulation and is for your information only.

Information with * are not required under the Spill Reporting Regulation but may be useful to the carrier

This template is for a carrier’s own use and convenience and may be modified to meet the carrier’s needs; however, the Spill Reporting Regulation requirements must be met. DELETE WORDS IN RED AFTERWARDS

|*Date of reporting: |*Time of reporting: |

|Person reporting the spill to PEP: |Phone number: |

|Address: |Email: |

|Responsible person (the person/company in possession, charge, and/or control of the |Phone number: |

|substance when it was spilled): | |

|Address: |Email: |

|Owner of the substance spilled: |Phone number: |

|Address: |Email: |

|Date of spill: |Time of spill: |

|Location of Spill Site: |

|Description of spill location and surroundings: |

| |

|*Distance to nearest public facility, residence, Indigenous community: |

|*Distance to nearest stream, water bodies, sensitive areas: |

|Description of source of spill: |

|Type of substance spilled: |Quantity of substance spilled: |

|Description of the circumstances, cause and adverse effects of the spill: |

| |

| |

|Actions taken to address the threat or hazard caused by the spill: |

| |

| |

| |

| |

|Check/tick the boxes below (advised of the spill and present at the spill site): |

|NOTE: Information is current as of Dec 2018. User must ensure contact numbers are correct and updated. Include any additional number as needed! |

|Agencies and name of person advised about the spill: |

|Provincial Emergency Program (1-800-663-3456); name of person: |

|Police/Fire Dept. (911); name of person: |

|Environment and Climate Change Canada (1800-668-6767); name of person: |

|Transport Canada (604-666-2955); name of person: |

|CANUTEC (1888-226-8832); name of person: |

|ICBC (1-800-663-3051); name of person: |

|First Nation Gov. Agencies; name of person: |

|Local government; name of person: |

|Others: |

|Agencies and name of person at the spill site: |

|Provincial Emergency Program (1-800-663-3456); name of person: |

|Police/Fire Dept. (911); name of person: |

|Environment and Climate Change Canada (1800-668-6767); name of person: |

|Transport Canada (604-666-2955); name of person: |

|CANUTEC (1888-226-8832); name of person: |

|ICBC (1-800-663-3051); name of person: |

|First Nation Gov. Agencies; name of person: |

|Local government; name of person: |

|Others: |

|*Other comments/actions taken: |

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|*Information Form completed by: |*Phone number: |

|*Title: |*Date: |

FYI: After the Initial Report, there are additional reporting required under the Spill Reporting Regulation.

For more information see .bc.ca/ReportaSpill webpage.

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