"Incident Report Form" - New York

Incident Report Form is a legal document that was released by the New York State Department of Environmental Conservation - a government authority operating within New York.

Form Details:

  • The latest edition currently provided by the New York State Department of Environmental Conservation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the New York State Department of Environmental Conservation.

ADVERTISEMENT
ADVERTISEMENT

Download "Incident Report Form" - New York

Download PDF

Fill PDF online

Rate (4.3 / 5) 21 votes
INCIDENT REPORT
State Pollutant Discharge Elimination System (SPDES)
General Permits (GP-0-16-001) OR (GP-0-16-002) for
Concentrated Animal Feeding Operation (CAFO)
. If for any reason, the owner/operator knows or has reason to believe that the following has occurred:
1. There is a discharge of process wastewater to the waters of the State that causes deposition, substantial
visible contrast or impacts to fish or other violations of 6NYCRR Parts 700 to 705; or
2. There is an overflow of manure, litter or process wastewater from a waste storage structure.
3. Any one of the conditions outlined is Part III.B.1 of the general permits for the discharge of Non-Contact
Cooling Water are not met.
The owner/operator shall:
Notify the DEC Regional Office (contact list attached) orally within 24 hours from the time that the owner/operator
becomes aware of the discharge or overflow as described above and submit this CAFO Incident Report Form to the DEC
Regional Office within 5 business days of the event. The owner/operator shall use the CAFO Annual Compliance Report
Form to report all other instances of non-compliance with permit conditions not listed on this CAFO Incident Report Form.
SPDES #
SECTION I: FACILITY INFORMATION
Facility Name:
Facility Address:
Facility County:
Facility Representative
and Title:
DEC Region:
DEC Division of Water
Contact:
Telephone No. : (_____) _____-_______
Date: ____/____/______
INCIDENT REPORT
State Pollutant Discharge Elimination System (SPDES)
General Permits (GP-0-16-001) OR (GP-0-16-002) for
Concentrated Animal Feeding Operation (CAFO)
. If for any reason, the owner/operator knows or has reason to believe that the following has occurred:
1. There is a discharge of process wastewater to the waters of the State that causes deposition, substantial
visible contrast or impacts to fish or other violations of 6NYCRR Parts 700 to 705; or
2. There is an overflow of manure, litter or process wastewater from a waste storage structure.
3. Any one of the conditions outlined is Part III.B.1 of the general permits for the discharge of Non-Contact
Cooling Water are not met.
The owner/operator shall:
Notify the DEC Regional Office (contact list attached) orally within 24 hours from the time that the owner/operator
becomes aware of the discharge or overflow as described above and submit this CAFO Incident Report Form to the DEC
Regional Office within 5 business days of the event. The owner/operator shall use the CAFO Annual Compliance Report
Form to report all other instances of non-compliance with permit conditions not listed on this CAFO Incident Report Form.
SPDES #
SECTION I: FACILITY INFORMATION
Facility Name:
Facility Address:
Facility County:
Facility Representative
and Title:
DEC Region:
DEC Division of Water
Contact:
Telephone No. : (_____) _____-_______
Date: ____/____/______
SECTION II: INCIDENT DESCRIPTION – Attach additional sheets as necessary
Date of incident: ____/____/_____
Duration of incident: ___________________
Volume of Discharge (in gals.) ______________
Type of incident:
(
)
Lagoon / Manure Storage
Overflow
Discharge
Vehicle/Spreader
Waste Transfer System Failure
Field Run Off
Production Area Run Off
Spill
Other
Description of incident(s) and cause(s) (include flow path to the receiving water and map/sketch if available):
Has Surface Water Been Impacted? (Y)___ (N) __ Distance To Nearest Surface Water Body ____________
Surface Water Body Name ________________________________________________________
Describe the deposition of solids, substantial visual contrast and impact to aquatic organisms in the receiving
water:
Has Groundwater Been Impacted? (Y) ___ (N) __ Have Public Water Wells Been Impacted? (Y) ___ (N) ___
Have Residential Wells Been Impacted? (Y) ___ (N) ___ How Many Wells? _____________
SECTION III: INCIDENT LOCATION
Provide at least one of the following for the incident location:
1) Latitude __________
Longitude __________
2) UTM X Coordinate __________
UTM Y Coordinate __________
3) Nearest Intersection to the incident Location
Distance and Direction from Incident to nearest Intersection
Page 2 of 3
SECTION IV: WEATHER CONDITIONS
Weather conditions during incident: ______________________________________________________
Rainfall previous 24 hours before incident: ________________________________________________
Rainfall previous week before incident: ___________________________________________________
SECTION V: CORRECTIVE ACTIONS
Immediate corrective actions:
Preventative (long-term) corrective actions:
SECTION VI: NOTIFICATION
Date, time of oral notification made to DEC: _____/_____/_____
____:____ (am) (pm)
DEC official contacted: _____________________________________________________
Planner notification: (Y) ___ (N) ___
SECTION VII: OWNER/OPERATOR CERTIFICATION
I certify under penalty of law that this Incident Report and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gathered and
evaluated the information submitted. Based on my inquiry of the person or persons who manage the system,
or those persons directly responsible for gathering the information, the information submitted is, to the best of
my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for
submitting false information, including the possibility of fine and imprisonment for knowing violations.
________________________
_________________________
____/____/_______
Name (please print or type
Signature
Date
Page 3 of 3
Page of 3