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									DEPARTMENT: Design and Construction              POLICY DESCRIPTION: Environmental –
                                                 Emergency Response
PAGE: 1 of 3                                     REPLACES POLICY DATED:
EFFECTIVE DATE: January 12, 1999                 REFERENCE NUMBER: DC.007

All Company facilities, including but not limited to, hospitals, ambulatory surgery centers, home
health agencies, physician practices, and all Corporate Departments, Groups and Divisions.

To require each facility to address any incident that may require facility personnel to follow
environmental emergency response procedures in accordance with applicable Environmental
Protection Agency (EPA) regulations.


Federal regulations require a facility to have a plan for emergencies or environmental disasters. Each
facility must develop one environmental emergency response plan that incorporates the requirements of
various applicable regulations. This plan should be reviewed, revised, if necessary, and re-certified by
qualified professionals annually to ensure that applicable regulatory elements are included. The
Corporate Environmental Manager is available to support this effort.

Communities are required by Federal regulations to develop a Hospital Emergency Response Plan to
address hospitals’ role(s) in community emergencies. A facility’s environmental emergency response
plan must be consistent with, and should incorporate by reference at a minimum, the community’s
Hospital Emergency Response Plan.

In the event of an unplanned release of hazardous substances, the facility must follow these basic
     protect people from injury;
     prevent further release of pollutants to the environment;
     protect property from damage; and
     report regulated release of pollutant to appropriate agencies.

This policy addresses federal regulatory requirements. State laws or regulations may impose
additional requirements. Each facility should consult with Corporate Engineering Services and the
facility’s Operations Counsel to identify and comply with any such additional requirements.

The most common incidents that may require environmental emergency response include:
    fire or explosion;
    toxic gaseous chemical (e.g. ethylene oxide, chlorine) leak;
    petroleum fuel spill;
DEPARTMENT: Design and Construction               POLICY DESCRIPTION: Environmental –
                                                  Emergency Response
PAGE: 2 of 3                                      REPLACES POLICY DATED:
EFFECTIVE DATE: January 12, 1999                  REFERENCE NUMBER: DC.007

      uncontrolled spill of chemicals or fuel to the storm drainage system;
      hazardous chemical spill; and
      natural disaster.
A facility’s environmental emergency response plan should incorporate the requirements of EPA’s
Resource Conservation and Recovery Act/Hazardous Waste Planning rules and the Occupational Safety
and Health Administration’s (OSHA) Hazardous Waste Operations and Emergency Response rules. If a
facility is subject to EPA’s Oil Pollution Prevention Rules, it must incorporate into its emergency
response plan the requirements of the Spill Prevention Control and Countermeasure Plans (attached).

Release reporting requirements vary based on regulations and agencies and can be complicated. Both
the immediate notifications and subsequent written reports that are required, and the required
circumstances and procedures, must be identified in each facility’s Environmental Emergency Response

The EPA hazardous waste generator ID for a facility must be provided to the appropriate agency during
a hazardous waste emergency reporting.

Asbestos fiber release that occurs during a fire, flood, or asbestos abatement project must be handled
jointly by the abatement contractor and facility personnel.

Medical waste spills on Company property must be responded to jointly by the person responsible for
infection control and the Environmental Services Department, and cleanup should be conducted
immediately. Medical waste spills outside the building must be reported to the appropriate state agency.
No reporting is required for medical waste spill inside the building if the spill is properly contained and
cleaned up.

Engineering Services (Plant Operation) personnel must respond immediately to Diesel fuel spills on
Company property. A fuel spill in excess of 24 gallons outside the containment area may require
reporting to the state emergency response agency.

Waste generated during an emergency must be disposed of in accordance with applicable waste disposal

EPA regulation: SARA Title III Section 302
OSHA Process Safety Management of Highly Hazardous Chemicals (29 CFR 1910.109)
Federal EPA National Contingency Plan, 40 CFR 110-112
Corporate Spill Prevention Control and Countermeasure Plan (attached)

                      Prepared For:
                     Name of Facility
                    Address of Facility

                       Prepared By:
            Corporate Environmental Engineering
              HCA – The Healthcare Company
                      One Park Plaza
                Nashville, Tennessee 37203


The Spill Prevention Control and Countermeasure (SPCC) plan for the Name of Facility at Address of Facility will be
implemented as herein described in accordance with "Title 40 - Protection of the Environment - Chapter 1 - Environmental
Protection Agency; Subchapter D -Water Program - Part -Oil Pollution Prevention". I hereby certify that I am responsible for the
operation of the above named facility.

Owner's Signature: _________________________________Date
Name/Title:      Name of CEO, Chief Executive Office
                 Name of Facility

Ooperator's Signature: ______________________________Date
Name/Title:       Name of Director of Plant Operation
                  Name of Facility

                                         ENGINEER'S CERTIFICATION

I have examined the facility and, to the best of my knowledge and belief, certify that this plan has been reviewed and has been
prepared in accordance with provisions of the federal regulations (40CFR 112) and good engineering practice. This certification
in no way relieves the owner or facility operator from preparing or fully implementing such plan in accordance with the
applicable regulations.

                                                      Certified By:

                                                     Y. Cindy Lin, P.E., Ph.D.
  (seal)                                     Manager, Environmental Engineering
                                                   1.0 INTRODUCTION
This plan was prepared in accordance with the Federal Regulations 40 CFR Part 112 "Oil Pollution Prevention." Spill
events subject to the SPCC plan, as in Federal Regulations 40 CFR Part 110.1, include, but are not limited to, "any
spilling, leaking, pumping, pouring, emitting, emptying and dumping of oil of any kind or any form, including, but not
limited to, petroleum, fuel oil, sludge, oil refuse, and oil mixed with wastes other than dredged spoil." The SPCC plan
identifies potential sources of oil spills and pollution, and develops procedures for corrective spill control and a plan to
prevent spill recurrence.

                                                TABLE OF CONTENTS

  Description of Major Topics                                                                 Corresponding Section
  •        Introduction                                                                        1.0
  •        General Facility Information                                                        2.0
  •        Facility Emergency Coordinator                                                      3.1
  •        Community Emergency Coordinator                                                     3.2
  •        Facility Description and Location                                                   4.0
  •        Emergency Response Procedures                                                       5.0
  •        Emergency Notification Procedures and Reporting Requirements                        5.3
  •        Evacuation Plan                                                                     5.5
  •        Area Specific Oil Spill Prevention Control Plan                                     6.0
  •        Emergency Response Training Procedures                                              7.0

                                    2.0 GENERAL FACILITY INFORMATION

2.1 Facility Identification
1.      Facility Name: Name of Facility
        Mailing Address:       Address of Facility
        Management Contact: Name of CEO, Chief Executive Officer
        Emergency Coordinator: Name, Director Plant Operation

2.       Corporate Ownership: Name of HCA Subsidiary
         Corporate Officer:       Name of CEO, Administration
         Mailing Address: One Park Plaza, Nashville, TN 37202
         Telephone:               (615) 344-2288
3.       Date operation began at this facility:     Date

2.2 Facility Description

1.       Location:        Give a short description of the facility. For example: The facility is bordered by Illinois
                          Central Railroad, East 31st Street, Martin Luther King Dr. and 26th Street.
2.       Site Map:        See Figure 1.(attach a map)
3.       Facility Layout: See Figure 2.(attach a drawing)
4.       Nature of Business:       Acute care/psychiatric care facility.
5.       Number of Employees: 800 (Approximate)
6.       Hours of Operation:       24 hours
7.       Days of operation:        7 days a week

                                        3.0 EMERGENCY COORDINATORS

3.1 Facility Emergency Coordinator
The designated emergency coordinator for the facility campus is Name of Director of Plant Operation. He can be
reached at (telephone number) and Home (Telephone number). Alternative emergency coordinator is Alternate person
at (Telephone Number). At all times, at least one of these employees is on the premises or on call, and has the
responsibility and authority to coordinate any emergency response measures necessary. This authority includes the
ability to commit funds and resources to properly handle the emergency. These emergency coordinators are thoroughly
familiar with all aspects of this SPCC plan, all operations and activities of the plan, the location and characteristics of
material handled, the location of all records, and the layout of the facility.

3.2 Local Community Emergency Coordinator
The contact of the Local Emergency Planning Committee (LEPC) as required by 40 CFR 112 regulations for the City
Name/ Name County emergency services is coordinated by the State Emergency Services and Disaster Agency and the
Metropolitan Water Name of your wastewater district:

The local 24-hour telephone numbers for purposes of emergency notification are:

                  (800)telephone or telephone
                  State Emergency Services and Disaster Agency
                  Address of agency

                  (Telephone of POTW (24 hours) (office hours)
                  Metropolitan Water Reclamation District of City
                  Address of agency

                                 4.0 FUEL STORAGE DESCRIPTION AND LOCATION
   Figure 3 presents the locations where the fuel storage facilities are located.
Facility               Location                      Use(circle applicable one(s))                   Remark
Tank #1                                              gasoline/diesel, generator/ heating             Backup for gas
Tank #2                                              gasoline/diesel, generator/ heating
Tank #3                                              gasoline/diesel, generator/ heating
Tank #4                                              gasoline/diesel, generator/ heating
Tank #5                                              gasoline/diesel, generator/ heating
Tank #6                                              gasoline/diesel, generator/ heating
Tank #7                                              gasoline/diesel, generator/ heating
Tank #8                                              gasoline/diesel, generator/ heating
Tank #9                                              gasoline/diesel, generator/ heating

                                     5.0 EMERGENCY RESPONSE PROCEDURES
   Under 40 CFR subparts 110 and 112, a facility owner or operator must maintain an effective emergency spill response
   system which includes early identification of a release and immediate notification to proper authorities. Not all releases
   requiring emergency notification will warrant activation of the local emergency plan. The criteria for agency reporting
   varies with the type of material, amount of release, and the environment of release. A release of fuel exceeding 25
   gallons to the ground needs to be reported within 24 hours. However, if an emergency poses imminent danger to the
   environment or public health, and cannot be controlled by the Facility personnel, the Emergency Coordinator must
   contact agency immediately.

   Whenever an incidental release (other than an authorized and engineered release) of any regulated materials, in a
   quantity which meets or exceeds the reportable quantity, occurs at the facility, the emergency coordinator in charge,
   upon discovery or confirmation of such release, should immediately report the release to the LEPC. In City/County, the
   emergency notice shall be given by telephoning emergency telephone numbers as designated in the check list at the end
   of this section.

   Other pertinent authorities to be contacted during the emergency are also listed below.

                                               State and Local Agencies to be
                                              Contacted During an Emergency

    •       State Emergency Services and Disaster Agency: (800) Telephone (24 hour emergency number)
    •       City Fire Department - 911
    •       City Metropolitan Water Reclamation District (In-facility spill to sanitary or storm sewer system)
    •       National Response Center - (800) 424-8802, if it is necessary to evacuate the nearby community.

            Other Pertinent Agencies
    •       State Environmental Protection Agency, Leaking Underground Storage Tank Section: Telephone

 •       State Fire Marshal Office, Petroleum and Chemical Safety - (Telephone)

5.2 Implementation of the Emergency Plan
The decision to implement the emergency plan depends upon whether or not an imminent or actual incident could
threaten human health or the environment. The purpose of this section is to provide guidance to the emergency
coordinator in making this decision by providing implementation criteria.

The emergency plan will be implemented in the following situations:

         1.       Injury to an employee when the injury is of such a serious nature that medical attention above the
                  level of first aid is required.
         2.       The spill cannot be contained on-site resulting in off-site soil contamination and/or ground or surface
                  water pollution.
         3.       Fire/Explosion or other emergency situation. Note: Call Fire Department at 911.

5.3 Spill Emergency Procedures
An emergency procedure checklist is provided at the end of this plan, beginning on page 10. The emergency
procedures, which will be followed by the emergency coordinator in implementing the emergency plan, are detailed

         A.       In the event of major emergencies, notify all employee and occupants of the situation. Evacuate
                  personnel, if deemed necessary. For general emergency situations, verbally alert personnel in the area
                  of the emergency. If time allows, proper containment procedures will be initiated under the direction
                  of the Emergency Coordinator.

         B.       Contact state and local agencies with designated response roles, if their assistance is required. Refer
                  back to the list in Section 5.0 for a list of the emergency telephone numbers for the appropriate

         C.       Whenever there is a release, fire, or explosion, the emergency coordinator will immediately identify
                  the character, exact source, and amount of any released materials and the extent of contamination.

         D.       Concurrently, the emergency coordinator will assess possible hazards to human health or the
                  environment that may result from the release, fire, or explosion. This assessment will consider both
                  direct and indirect effects of the release, fire or explosion (e.g., the effects of any toxic, irritating or
                  asphyxiating gases that are generated, or the effects of any oily surface runoff from water or chemical
                  agents used to control fire and heat-induced explosions).

         E.       If the emergency coordinator determines that the facility has a release, fire or explosion which could
                  threaten human health or the environment outside the campus, he/she will report the findings as

                  1.       If the assessment indicates that evacuation of local areas may be advisable, he/she will
                           immediately notify local authorities. He/she will be available to help appropriate officials
                           decide whether local areas should be evacuated.

                  2.       The emergency coordinator will immediately notify either the government official
                           designated as the on-scene coordinator for the geographical area of the LEPC. Reports to
                           these agencies must include:
                           a.       Name and telephone number of the reporter;
                           b.       Name and address of the facility;
                           c.       Time, date, location and type of incident (e.g., release, fire);

                           d.       Name and quantity of material(s) involved, to extent known;
                           e.       Exact location of the release/spill;
                           f.       The extent of injuries, if any;
                           g.       The possible hazards to human health or the environment outside the plant; and
                           h.       Actions taken for containment or cleanup.

         F.       During an emergency, the emergency coordinator will take all reasonable measures necessary to
                  ensure that fires, explosions and releases do not occur, recur or spread to other areas. These measures
                  will include, where applicable, stopping operations, collecting and containing released fuel, and
                  removing or isolating the source of the spill.

         G.       Immediately after an emergency, the coordinator will provide the means for treating, storing or
                  disposing of recovered materials, contaminated soil, or surface water, or any other waste material that
                  results from a release, fire or explosion at the plant. Depending on the quantity of the material
                  released, the emergency coordinator will select the proper disposal means and obtain approval from
                  state and local officials.

         H.       The Emergency Coordinator will ensure that, in the affected area(s) of the facility:
                  1.     No materials that may be incompatible with the release material are treated, stored or
                         disposed until cleanup procedures are completed; and

                  2.       All emergency equipment listed in the contingency plan is cleaned following the proper
                           decontamination procedures for its intended use before operations are resumed. Any
                           contaminant should be removed from the equipment before the maintenance work is
                           performed. The subsequent equipment cleanup, repair and maintenance tasks should
                           carefully follow the instruction manuals furnished by the manufacturers of that particular
                           equipment. The Emergency Coordinator will inspect the equipment and sign the incident

         I.       The Emergency Coordinator should notify, in writing, the appropriate state and local authorities that
                  the area is in compliance with the pertinent ordinance before operations are resumed in the fuel
                  storage tank facility.

         J.       The Emergency Coordinator will log the time, date, and details of any incident that requires
                  implementing the contingency plan in the operating record.

         K.       Within fifteen days after the incident, a written report will be submitted to the LEPC and State
                  agencies. The report will include:

                  1.       Name, address, and telephone number of the company;
                  2.       Date, time, location and type of incident (e.g., fire explosion);
                  3.       Name and quantity (by weight or volume) of material(s) involved;
                  4.       The extent of injuries, if any;
                  5.       An assessment of actual or potential hazards to human health or the environment, where
                  6.       Countermeasure action taken during and after the incident; and
                  7.       Estimated quantity and disposition of recovered material that resulted from the incident.

In addition to these reporting requirements for State and Federal authorities, the Company also has internal reporting
requirements. The following incidents require that an incident report be completed and returned to the Risk
Management Department (615)344-5854 within one (1) working day and made part of the operating record:

         1.       All fires;
         2.       Hazardous liquid or oil spills;
         3.       All injuries-NO MATTER HOW SLIGHT;
         4.       All major equipment damage due to malfunction or operating error; and
         5.       All "near misses" of the above variety that could have had serious consequences.

5.4 A list of emergency Oil Spill Response Capability

5.4.1 Emergency Equipment List
A list of the location of safety and emergency equipment available on campus is located at the Plant Operations
Department and Environmental Service Department. Available equipment includes communications equipment (not
shown on the facility plan since they are located in many areas around the campus), fire extinguishers, first aid kits,
emergency showers and eyewash stations, and spill control equipment.

The Safety Equipment List is a list of equipment available for spill control. Inspection, inventory, and operational
checkouts of this unit and all equipment should be performed monthly. At the conclusion of the use of spill control
equipment, materials should be restocked. It should be noted here that dry chemical fire extinguishers are provided in
accordance with pertinent state guidelines and local codes.

As seen in the Safety Equipment List, there are various types of personnel protection equipment in the spill control unit
such as a first aid kit, disposable coveralls, boots, gloves, and visors with face shields.

Personnel protection equipment is provided in accordance with OSHA regulations for all employees. Container Room
personnel are provided with respirators, disposable coveralls, gloves, and goggles.

5.4.2 Emergency Spill Response Procedures
In case of a spill within diked or contained areas:
 1.      Stop flow of product, if possible.
 2.      Make sure product stays within dike or containment. Check dike perimeter or containment structure for leaks
         and, if present, reinforce the spill location with absorbent or appropriate available materials.
 3.      Contact the Emergency Coordinator (__________).
 4.      Berm or trench around spill, as necessary, to prevent flow or migration of product to storm sewer or natural
         drainage way.
 5.      Contact the local HAZMAT Response Team

In case of spill in other areas:
 1.        Stop flow of product, if possible.
 2.        Berm or trench around spill, as necessary, to prevent flow/migration of product to storm sewer or natural
           drainage way.
 3.        Concurrently or immediately after the spill, contact the Emergency Coordinator.
 4.        Contact the local HAZMAT Response Team (911)

In case of fire/explosion:
 1.      Use fire extinguisher(s) to extinguish the fire, if possible.
 2.      If a fire is not controllable, activate fire alarm system and call the fire department immediately (911), and
         evacuate the area.
 3.      Contact Emergency Coordinator in charge of the spill control.

Additional Assistance Sources:
 1.     State Fire Marshal Office, Petroleum and Chemical Safety: (Telephone)
 2.     Emergency Chemical Information Assistance: (800) 424-9300

5.4.3 Additional Emergency Action
 1.     Do not use any material that is incompatible with the spill material(s).
 2.     Place spent absorbent in metal, leak-tight drums, label and dispose of expended absorbent properly.

5.5 Disaster Plan
An evacuation plan has been developed for all buildings on facility campus to provide for the safe exit of personnel
should evacuation become necessary. In case of fire, explosion, tornado or other emergency conditions which if
determined by the designated supervisor on duty, threatens the safety of facility personnel, the Disaster Plan will be
activated by the Facility Chief Executive Officer or his/her designee. Telephones located throughout the campus will be
used to inform supervisory personnel to begin evacuating their employees. Evacuation routes to be used, including
alternates, are posted in all buildings. All Name of Facility personnel should be briefed frequently on evacuation
procedures. When the evacuation plan is activated, local authorities must be notified. The notification/reporting
procedures are described in detail within the Emergency Procedures Checklist.

                                     6.0 OIL SPILL PREVENTION CONTROL

In-Facility Spills
In-facility spills of any hazardous materials will be dealt with by personnel knowledgeable with the particular chemical
which has been released. Building maintenance personnel who handle hazardous materials are trained in the orientation
program and have on-the-job training. They are very familiar with the materials they handle, as well as emergency
procedures, in the event that particular material is released. Note: As long as the spill is contained and cleaned up inside
the building, or within the containment, no agency reporting is required.

Inspection of Fuel Storage Facility
The Emergency Coordinator will make every effort to inspect all fuel storage tank facilities at least monthly. These
inspections will include:

 •       inspection of exterior surfaces of any above-ground tanks or containers, valves, piping network and any other
         auxiliary equipment for signs of leaks and maintenance deficiencies;
 •       inspection of all leak detection and monitoring equipment to ensure that it is properly functioning;
 •       identification of cracks, areas of wear, corrosion and thinning, excessive settlement of structures, structural
         and/or foundation weakness, separation or swelling of the tank insulation, and signs of malfunctioning
         equipment; and
 •       indications of poor maintenance and operating practices.

The reports for the monthly inspection will be retained in the Plant Operations Department. The secondary containment
system needs to be constructed so that spills will not permeate, drain, infiltrate or escape to the groundwater, surface
water or soil environment before cleanup begins.

The drainage that is collected inside the secondary containment system will be controlled by a gravity drain pipe which
has a manually-controlled pipe valve located on the outside of the dike. Clean surface water may be discharged to the
existing stormwater system. Drainage that is contaminated should be diverted to the sanitary system (if the criteria
established in the existing pretreatment ordinance are met) or be treated prior to discharge to the stormwater system.

Drum Storage
Except for transporting or momentary staging prior to use, all drums containing hazardous substances will be stored
within a proper containment facility in case of leakage or spillage. The following are precautions to be taken by the
operation personnel:

 •       Loading and unloading of hazardous substances should be performed in a controlled space on an impermeable
 •       Drummed materials obtained from the storage area should be delivered to the point of usage under cover as
         soon as possible.
 •       Unless appropriate decontamination is performed, empty drums which previously contained hazardous
         materials should be handled as that with content. Empty drums should be returned to the vendors.
 •       All drums should be properly labeled according to the contents and recommended disposition.
 •       Drums containing waste materials should be handled and disposed of in accordance with the applicable federal
         and state regulations

 •       Holding capacity of the secondary containment system in the drum storage area should be at least 10% of the
         total storage capacity.


It is critical that all Plant Operations and Environmental Services employees are familiar with SPCC requirements. To
accomplish this, the following procedures should be considered and implemented:

 1.      All pertinent managerial and supervisory personnel are required to read and be conversant with the contents of
         the SPCC Plan and the impact if a fuel spill occurs.
 2.      All employees are to be familiar with the requirement to report all spills to their supervisor.
 3.      All Plant Operations employees are to be familiar with:
         a. The facility drawing and SPCC Plan,
         b. The materials and equipment available for control and cleanup of spills, and
         c. The Emergency Procedures Checklist.
 4.      A meeting of managerial and supervisory personnel to discuss the SPCC procedures should be held shortly
         after receipt of the "Plan" or revisions to the SPCC Plan.
 5.      To keep spill prevention a high priority issue, short meetings should be held or bulletins issued at regular
         intervals to "update" the SPCC Plan and to instruct any new employees on the requirements.
 6.      The data and those in attendance at each SPCC meeting should be recorded and these records kept with any
         bulletins issued.
 7.      As the recommended improvements are completed, the date of completion and the specific area of concern
         should be recorded.
 8.      The SPCC Plan will be reviewed and revised, as appropriate, at least once every three years and the Plan will
         be certified by a licensed professional engineer (per 40CFR 112).

7.2 SPCC Plan Copies
A copy of the SPCC plan and all revisions will be:
  •     Maintained at the facility, and
  •     If requested by the agency, a copy will be submitted to the Local Emergency Planning Committee to provide
        emergency response services at the facility.

This SPCC plan will be reviewed and immediately amended, if necessary, whenever:

 •       the SPCC fails in an emergency;
 •       the facility changes in its design, construction, fuel oil use, operation, maintenance or other circumstances in a
         way that increases the potential for fires, explosions or releases of oil or changes in the response necessary in
         any emergency;
 •       the list of emergency coordinators changes;
 •       the list of emergency equipment changes;
 •       upon request of local or state agencies, with the written justifications provided by the agency; or
 •       at least once every three (3) years.

7.3 Recordkeeping
A complete emergency record will be maintained by the Emergency Coordinator. The emergency record includes the

 1.      Personnel Training Record;
 2.      Inspection and Official Visit Records;
 3.      Safety/Facility Improvement Records;
 4.      Facility Testing and Equipment Inspection Records; and
 5.      Fuel Oil Inventory Records.

An emergency phone list for persons to be contacted in the event of an emergency should be posted near phones in areas
where fuel oil is stored and/or handled.

                                   EMERGENCY PROCEDURES CHECKLIST
                                            Name of Facility

(Be prepared to provide response agencies with the information marked with an asterisk (*) on this checklist. Response
agencies may also be called for assistance inside facility boundaries.)

*1.      Did the contaminant release enter navigable waters of the United States (Lake River or storm sewer/tributary to
         the Lake/River).
         YES (__) NO (__), If yes, see Notification Requirements (#10). Provide brief explanation of emergency
         conditions as outlined in Items 2 through 9.

*2.      Facility: Name of Facility, Address of Facility

*3       Name of Emergency Coordinator completing this checklist:
         Name: __________________________Telephone Number:_________________

*4       Date:______________, Time of Incident_____________________

*5.      Exact location of the spill or emergency incident:

*6.      Material Involved:___________________ Quantity__________________

*7.      Source of Oil Spill/Release:

*8.      Cause of Oil Spill/Release or Emergency Incident:

*9.      Name of nearest body of water or sewage treatment plant threatened or involved in spill/chemical release:

10.      Notification Requirements:
         If the incident involves:
         a.        A spill exceeding reportable quantities escaping a facility building OR
         b.        An emergency which threatens public health and/or the environment.
Note: The State Emergency Services and Disaster Agency has notification procedures through which they will contact EPA
Region __and the National Response Center.

11.      Is evacuation of the entire building necessary? Yes ___ No ___
         If answer is YES, note the time an alarm was sounded.
         _____________A.M./P.M. (Circle one)

12.      Are Outside Emergency Response Agencies Needed? YES (___) NO (___)
         If yes, contact primary emergency response agencies as needed. If additional assistance is needed call second
         Fire:     city Fire Department        Dial 911
         Police: city Police Department            911

13.      Hazard to human health or environment outside the facility (meaning outside facility buildings?) YES (___)
         NO (___)

         If yes, Brief explanation of Hazard: See Notification Requirements (#10).


14.    Evacuation of areas outside the facility necessary?
       YES (___) NO (___). If no, then go to question 15.

       If yes, contact Police to aid in the evacuation. Record the following information:
       AGENCY                        PERSON                      TIME                TIME ON
       CONTACTED CONTACTED CALLED                                SCENE
       (If there is only in-house evacuation, then police contact is not necessary.)

15.    Extent of Injuries, if any:

*16.   Description of Response Activities:

17.    For emergency chemical information assistance:
       Call State Fire Marshal, Petroleum and Chemical Safety (telephone) or CHEMTREC (800) 424-9300.

                                                     - 10 -
                                            SAFETY EQUIPMENT LIST

The following list is an example, the DPO must develop a facility-specific list.

•        Stationary mount lamps to light up around above-ground storage tank facility.
•        2 swivel mount lights that can be directed from inside the containment building; one in the front and one in the
•        2 portable light stand lights with twist lick plugs and 100 ft. of 3-wire cord each.
•        1 - foldable stretcher.
•        1 - medium sized first aid kit.
•        Safety non-sparking tools with tool mounting holders.
                    Forks - manual
                    Shovels scoop
                    Rakes R-10
                    A-5 ax
                    crescent wrench
•        2 - case 1417 coverall - disposable.
•        Medium sized boots.
•        2 visors with face shields.
•        2 - streamlite portable lights.
•        1 - cases Norton latex gloves.
•        2 - cases of rags to hold absorbent material after it has been used.
•        50 + lbs. of absorbent material.
•        2 - fire extinguisher 10 lb. dry ABC with mounts.
•        100-feet of yellow rope with small stands and "Danger No Admittance" signs and 10 small stands to rope off
         an area.

                                                         - 11 -
                       PERSONNEL TRAINING RECORD
                              Name of Facility

Purpose of this Training

 NAME OF ATTENDEE          SIGNATURE               DATE

                                  - 12 -
                        Name of Facility
AGENCY             PURPOSE                 REMARK   DATE

                             - 13 -
                         Name of Facility
Maintenance Item     Performed by      REMARK       DATE

                              - 14 -
                        Name of Facility
Date   Tank/Line/Valves   Containment/Man-   Tank Gauge   Inspected
                          hole               Reading      by

                                - 15 -

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