Major Spill Form : STAR Park : Texas State University

Company Name *

Reporting Person *

Date and Time Spill Occurred/Discovered *

Location (Building) *

Location (Room) *

Material(s) Spilled *

Estimated Amount Spilled *

Were any personnel exposed to the spilled chemical? Describe any possible exposure, including contact, ingestion, or inhalation *

Was there any soil or water contamination? Describe. *

Was there any contamination of storm sewers or sanitary sewers? Describe. *

Describe how the spill occurred to the best of your knowledge. Include any relevant circumstances in as much detail as possible. *

What containment measures were taken to control and clean up the spill? Describe. *

What disposal methods of materials were used in the cleanup of the spill? Describe. *

List the agencies contacted *

Name and Contact Information for Emergency Responders and Law Enforcement *

Name and Contact Information for Witnesses to the Event *