NCS000399_Jacksonville Spill Incident Report_20190809

- Spill Incident Report Form
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Address p.
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Date/Time Started:
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Date/Time Ended:
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Cloud Cover
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Precipitation Conditions
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Temperature °F
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Wind Direction & SPee
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Incident Location
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Type Material
Spilled/Released
Damages or Injuries? NO YES O (if yes, describe):
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Spill/Release into/onto (Check applicable box(es)):
Containment ❑
Ground
Sewer ❑
Amount Spilled/Released to each media checked.
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Amount Recovered from each media checked.
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Product/Material Source Containers
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Total Capacity of Spill Source Container(s)
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Equipment Repairs/Replacement Needs
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If spill entered interior sewer inlet, was spill contained by OWS?
YES
NO O
C I spill impact adjacent properties? NO O YES (if yes, describe):
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Description of What Caused the Release: r
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Corrective Actions Taken: rM NOnie4rm
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Agency & Telephone #
Contact Name
Date
Time
Local Emergency: 911
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NCDENR 919-733-3300
800-858-0368
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NRC: 800-424-8802
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Other:
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Instructions Given B A encies --
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Preparer of Spill Report Print Name) Mature
Date
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Land Treatment Facility Spill Prevention Control & Countermeasures Plan
February 2009 Appendix C

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Illicit Discharge Field Reporting Form
Data Collection Farm
Date: _ Time: 1 !c q . GPS
Time since Last Rain: 1 cac2R.S2
•" Z quantity of Last Rain:
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Inspectionteam: �.taf� Di/L B&44ri
Site Description:(Locationand Narrative Desuiption-Include owner name, address, number) Zv USWe
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Type of Discharge or SpGreaseill wage Pool Trash Other
Type of Structure Spill occurred from: Open Channel Manhole Outfall Stormdraln Ditch Other /r�Y'�"'%4
Type of Structure spill is flowing "to": Open Channel Manhole Outfall Stormdrain Ditch O.thery {' yC,-J r-j1r' -`v3 Lo-k—
Dominant Watershed Land Uses: Industria Commercial Residential Unknown Other
Estimated Volume of Discharge rSpill: � ti 9�• a �aKS Cr-tay b2 �C1i�e-t' Y'Nwn't too,�r` 7
Was Flow Observed?' Was Laboratory Sample Collected? Yes No
� 'wto taken? Yes No
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Odor: None Musty Sewage Rotten Eggs Sour Milk Other 4^
Color: None Red Yellow Brown Green Grey Other
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Clarity: Clear Cloud 'Opaqu
Floatables: None ily She Garbage/sewage Other
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Deposits/Stains: None Sediment Oily Other
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Vegetation Conditions: None Normal Excessive Inhibited
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Structural Condition: Normal Concrete Cracking Metal Corrosion Other
Biological: Mosquito Larvae Bacterial/Algae Other ..
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Comments/ recommendations: fV.%4e V% dte" Jo tghw J t}N e-1( �{[
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Action Taken: Gr` Jt io 5 1 �L - i at UckyLG -(d.4_ "e- -Do>.
L Sheet Filled Out B(Signature)_fG.levi� 'I•
y: Date: L9
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Second Inspection
Name: c6rV A ,Ae.rry.^
Contact Phone Number: (119) 4 5 9- <o7 I
Original Date of Discharge:�®T Zo i 9
Location: PooO LSOn1 GTe¢.E # 149LI 270o &M-19A &W ?M'D.
Owner Name, Address and Phone number: VAjiw Qcek�tvL9 TuG 906t Al C- (Q)O) ZSQ' ZOES3
Results of Samples Taken: No 911"pLES 'rr "IV FRQALk Srt£
Was Photo Taken? Yes No
Was flow still observed? Yes No
Were actions taken on initial visit followed: Yes \LNo Explain: GLEAN vP EFr69:r-S
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Any further Actions required? Yes_, No
List Actions: Tk}E 3ACk5oNVYLL0 frgE 'DEPAerpABNr .SECvttep rAE: SCVt-iE
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To F 0 pLE of- TRC- ENvrP r/
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Data Sheet Filled Out By: (Signature) �i �Nn far„ Date:

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