FORM A
OIL SPILL/LEAK NOTIFICATION REPORT (FORM A)
Report must be submitted within 24hrs of Spill Incidence
Company Name
*
Section A: Incident Details
Date of Incidence
*
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Day
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Month
Year
Time of Incidence
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1
2
3
4
5
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8
9
10
11
12
:
Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date of Observation
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Day
-
Month
Year
Time of Observation
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1
2
3
4
5
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8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Spill Reference No
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Survey By
*
Foot
Boat
Helicopter
Overlook
Weather
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Sun
Clouds
Fog
Rain
Snow
Windy
Level of Impact
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No Impact
Slight Impact
Heavy Impact
Estimated Quantity Spilled
*
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Section B: Site Details
Site Name
*
OML
*
GPS FIELD POINTS
*
Total Length in meters
GPS FIELD POINTS
*
Length Surveyed in meters
Differential GPS
*
Yes
No
Spill Start Point GPS: EASTINGS
*
meters
Spill End Point GPS: EASTINGS
*
meters
Site area
*
Land Swamp
Fresh Water
Mangrove
Coastline
Near Shore
Off Shore
Other
Containment Measures in Place
*
Boom
Trenches
Bund wall
Sorbents
Others
Type of Contaminant
*
Crude Oil
Condensate
Chemicals
Refined Products
Others
Facilty
*
Pipeline
Flow line
Wellhead
Manifold
Flow Station
Rig
Storage Tank
Compressor Plant
Other
Properties at Risk
*
Farmland
Fish Pond
Vegetation
Fishing Net
Surface water
Venerable Objects
Other
SURVEY TEAM NO Name
*
Organization
*
Phone Numbers
*
REPORTING OFFICER:
*
DESIGNATION
*
SIGNATURE
*
Date
*
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Day
-
Month
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
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