Form CSB21001 "30 Day Written Spill Report Form" - Saskatchewan, Canada

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Ministry of Environment
Discharge ID / Spill Report Number
30 Day Written Spill Report Form
December 2015 | CSB | CSB21001
A. Reporting Requirements
How do I report a discharge?
Web: the preferred method is to sign in to our Online
Ÿ
Services and submit it through your company’s business
Call the Ministry of Environment at 1-800-667-7525 (note:
Ÿ
portal. In the portal you can apply for and receive
this number IS NOT intended for general inquiries. It is an
permission, fill out forms and submit documents online,
emergency line for reporting spills only.
review documents, and track your interactions with the
Submit this report within 30 days of the date the
Ÿ
ministry. Please visit the website:
discharge occurred.
http://www.environment.gov.sk.ca/online-services.
This report ensures timely reporting of discharges that may
Mail: you can complete the report, save and print it, and
Ÿ
cause or have caused adverse effects, and collects appropriate
mail the hard copy to:
details about the discharge.
Environmental Protection Branch
What do I report? This report requires the person reporting to
Hazmat and Impacted Sites Unit
have detailed information about the discharge and discovery,
including the following:
102 - 112 Research Drive
Site location
Saskatoon, SK S7N 3R3
Ÿ
Responsible party
Ÿ
Substances involved in the occurrence
What if I have questions? For assistance completing this
Ÿ
application or for more information, please contact our Client
Surrounding land use
Ÿ
Service Office:
Agencies involved in the discharge
Ÿ
Email:
centre.inquiry@gov.sk.ca
Tel (toll free in North America): 1-800-567-4224
What happens next? Once the report is submitted, the
Tel (Regina): 306-787-2584
ministry reviews it to determine its acceptability, in some
cases in consultation with individuals involved in the
NOTE: This form meets Environment Canada’s reporting
discharge/discovery, and may include other agencies and
requirements when submitted as soon as feasible in accordance
impacted landowners. If the report is not acceptable, the
with Federal legislation regulations. It may be submitted to
ministry identifies deficiencies and requests that it be
Environment Canada
improved. There are numerous ways to obtain closure and the
by email (preferred):
Ÿ
user should consult the impacted sites guidance document.
ec.dalesaskatchewanrpn-eedsaskatchewanpnr.ec@canada.ca
Ÿ
or by mail:
Ÿ
How do I submit the report? You can submit this application
Environment Canada
to the Ministry of Environment using our online services or by
Room 300 - 2365 Albert Street
mailing a hard copy.
Regina, SK S4P 4K1
B. Person Reporting
Company Name
Last Name
First Name
Middle Name
Address
Address
City
Province
Postal Code
Country
Mailing Address
Same as above
Different from above:
Address
Address
City
Province
Postal Code
Country
Contact Details
Phone (main)
Phone (work)
Phone (mobile)
Email
Preferred Method of Contact
Phone
Email
Mail
1 of 4
PRINT
CLEAR
Ministry of Environment
Discharge ID / Spill Report Number
30 Day Written Spill Report Form
December 2015 | CSB | CSB21001
A. Reporting Requirements
How do I report a discharge?
Web: the preferred method is to sign in to our Online
Ÿ
Services and submit it through your company’s business
Call the Ministry of Environment at 1-800-667-7525 (note:
Ÿ
portal. In the portal you can apply for and receive
this number IS NOT intended for general inquiries. It is an
permission, fill out forms and submit documents online,
emergency line for reporting spills only.
review documents, and track your interactions with the
Submit this report within 30 days of the date the
Ÿ
ministry. Please visit the website:
discharge occurred.
http://www.environment.gov.sk.ca/online-services.
This report ensures timely reporting of discharges that may
Mail: you can complete the report, save and print it, and
Ÿ
cause or have caused adverse effects, and collects appropriate
mail the hard copy to:
details about the discharge.
Environmental Protection Branch
What do I report? This report requires the person reporting to
Hazmat and Impacted Sites Unit
have detailed information about the discharge and discovery,
including the following:
102 - 112 Research Drive
Site location
Saskatoon, SK S7N 3R3
Ÿ
Responsible party
Ÿ
Substances involved in the occurrence
What if I have questions? For assistance completing this
Ÿ
application or for more information, please contact our Client
Surrounding land use
Ÿ
Service Office:
Agencies involved in the discharge
Ÿ
Email:
centre.inquiry@gov.sk.ca
Tel (toll free in North America): 1-800-567-4224
What happens next? Once the report is submitted, the
Tel (Regina): 306-787-2584
ministry reviews it to determine its acceptability, in some
cases in consultation with individuals involved in the
NOTE: This form meets Environment Canada’s reporting
discharge/discovery, and may include other agencies and
requirements when submitted as soon as feasible in accordance
impacted landowners. If the report is not acceptable, the
with Federal legislation regulations. It may be submitted to
ministry identifies deficiencies and requests that it be
Environment Canada
improved. There are numerous ways to obtain closure and the
by email (preferred):
Ÿ
user should consult the impacted sites guidance document.
ec.dalesaskatchewanrpn-eedsaskatchewanpnr.ec@canada.ca
Ÿ
or by mail:
Ÿ
How do I submit the report? You can submit this application
Environment Canada
to the Ministry of Environment using our online services or by
Room 300 - 2365 Albert Street
mailing a hard copy.
Regina, SK S4P 4K1
B. Person Reporting
Company Name
Last Name
First Name
Middle Name
Address
Address
City
Province
Postal Code
Country
Mailing Address
Same as above
Different from above:
Address
Address
City
Province
Postal Code
Country
Contact Details
Phone (main)
Phone (work)
Phone (mobile)
Email
Preferred Method of Contact
Phone
Email
Mail
1 of 4
C. Responsible Party
Legal Name
Business Name
Address
Address
City
Province
Postal Code
Country
D. Fixed/Storage Facility Information (if applicable)
Facility Code
Operation Identification
E. Discharged Material Details
Shipping Name
Material Code (UNPN/NA #)
Chemical Abstract Service Registry (CAS) #
Material Comments
(include phase: solid, liquid gas
Concentration of Liquid Released (mg/kg)
Type of Package or Containment
Classification
Total Mass/Volume
Mass or Volume
Prior to Discharge
of Discharge
Units
Units
F. Pressure Vessel Details (if applicable)
Pressure Vessel
Yes
No
Certification Safety Marks
Description of Failure
G. Discharge Details
Date of Occurrence (DD/MM/YEAR)
Description of Events
Please attach any additional information as a separate document.
Discharge Rate
Discharge Rate Units
Temperature
Duration of Discharge
Wind Speed (kph)
Wind Direction
Precipitation Type
Cloud Cover
Relative Humidity (%)
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Emergency Response
Measures, and
Subsequent
Assessment and
Corrective Actions
How impacted
materials were
disposed of
Closures resulting
from spill
(infrastucture
disruptions ie. road
closures etc.)
Actions taken to
prevent similar
incidents in the future
Long-term
corrective actions
(attach corrective
action plan if more
space required)
Other details
H. Discharge Location
Enter the Latitude/Longitude for center of the site in degrees, minutes, seconds.
Latitude:
Longitude:
Deg:
Min:
Sec:
Deg:
Min:
Sec:
Address
Address
City
Province
Postal Code
Country
3 of 4
I. Distances and Direction to:
Nearest Community
Name
Direction
Distance
Nearest Well
Name
Direction
Distance
Nearest Surface Water Body
Name
Direction
Distance
Nearest Occupied Building
Name
Direction
Distance
Surrounding Land Use (within 500 m of discharge location)
Check all that apply
Industrial
Commercial
Residential/Parkland
Agricultural
J. Transportation Occurrence Details (if applicable)
Road
Rail
Air
Marine
Type of Vehicle/Means of Containment
K. Emergency Response Assistance Plan (ERAP)
ERAP Number
ERAP activated?
Yes
No
L. Effects on Public
Public evacuated?
Yes
No
Public sheltered in place?
Yes
No
Number of People Affected
Number of Deaths
Number of People Requiring Medical Aid
M. Emergency Response Agencies
Organization Type
Agency Name
Police
Organization Type
Police
Agency Name
Organization Type
Agency Name
Police
Organization Type
Police
Agency Name
Organization Type
Agency Name
Police
Organization Type
Agency Name
Police
N. Conditions for Submission
If reporting by regular mail, please make sure all related documents are included or attached as part of the submission.
I have read and I fully understand that these conditions must be met before the Ministry of Environment can accept, assess
and process my report, and
Date of Report
I have read and I fully understand the requirements of this report, and
wish to continue with my report, and
I certify that the information I have provided in this report is true and
Signature of Reporter
accurate in every respect.
By checking this box, I accept these conditions.
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