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: |
| |
| |
|*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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