Form OG-12A Permittee Spill Report Form - Illinois

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ILLINOIS DEPARTMENT OF NATURAL RESOURCES
Office of Oil and Gas
One Natural Resources W ay
Springfield, Illinois 62702-1271
(217) 782-7756
OG-12A PERMITTEE SPILL REPORT FORM
Form required to be submitted within 90 days after date of spill.
PERMITTEE: _________________________________________________________________ PERMITTEE #: _______________
LOCATION:
IEMA # (if applicable) _______________________
PROPERTY /LEASE NAME: _____________________________________________________________________________________________
TANK #: ___________________________ PIT #: ____________________________ REFERENCE #: ________________________________
SECTION: __________ TOWNSHIP: ________________ RANGE: _______________ COUNTY: ____________________________________
TYPE OF SPILL
OIL
VOLUME LOST _______________________________
VOLUME RECOVERED _______________________________
WATER
VOLUME LOST _______________________________
VOLUME RECOVERED _______________________________
CONTAMINATED:(area
size)__________________________________________________________________________________________
DATE SPILL BEGAN: __________________________________________
EST. TIME BEGAN: __________________________________
DATE AND TIME SPILL REPORTED: ____________________________ REPORTED BY: _____________________________________
CAUSE OF SPILL
FLOWLINE
TANK
CONTAINMENT DIKE
WELL
STORAGE STRUCTURE
OTHER (specify) _____________________________________________________________________________________________________
DESCRIBE IN DETAIL CAUSE OF SPILL:
REMEDIAL ACTION
Describe emergency response measures:
Provide detailed description of overall clean-up actions (attach TPH analysis for oil spill): _
ILLINOIS DEPARTMENT OF NATURAL RESOURCES
Office of Oil and Gas
One Natural Resources W ay
Springfield, Illinois 62702-1271
(217) 782-7756
OG-12A PERMITTEE SPILL REPORT FORM
Form required to be submitted within 90 days after date of spill.
PERMITTEE: _________________________________________________________________ PERMITTEE #: _______________
LOCATION:
IEMA # (if applicable) _______________________
PROPERTY /LEASE NAME: _____________________________________________________________________________________________
TANK #: ___________________________ PIT #: ____________________________ REFERENCE #: ________________________________
SECTION: __________ TOWNSHIP: ________________ RANGE: _______________ COUNTY: ____________________________________
TYPE OF SPILL
OIL
VOLUME LOST _______________________________
VOLUME RECOVERED _______________________________
WATER
VOLUME LOST _______________________________
VOLUME RECOVERED _______________________________
CONTAMINATED:(area
size)__________________________________________________________________________________________
DATE SPILL BEGAN: __________________________________________
EST. TIME BEGAN: __________________________________
DATE AND TIME SPILL REPORTED: ____________________________ REPORTED BY: _____________________________________
CAUSE OF SPILL
FLOWLINE
TANK
CONTAINMENT DIKE
WELL
STORAGE STRUCTURE
OTHER (specify) _____________________________________________________________________________________________________
DESCRIBE IN DETAIL CAUSE OF SPILL:
REMEDIAL ACTION
Describe emergency response measures:
Provide detailed description of overall clean-up actions (attach TPH analysis for oil spill): _
Show on plat below areal extent of spill affected area and TPH sample locations for each composite sample documenting
spill remediation.
MAP
SCALE
(Check grid size used)
5 ft.
10 ft.
20 ft.
50 ft.
100 ft.
N
W
E
S
TPH SAMPLE
LOCATIONS
OIL WELL
TANKS
===== ROADS
-------- STREAMS
/ / / / / AREA OF SPILL
______ FLOWLINES /
INJECTION LINES
PREVENTIVE SPILL MEASURES
Describe what measures have been implemented to help prevent spills of similar nature in the future. Use additional sheet if necessary.
___________________________________
____________________________
Permittee or designee
Date
Department Use Only
The spill remediation is completed pursuant to Department rules and is released.
_____________________________________________
_____________________________
Department representative
Date

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