24_Spill Response Policy and Forms Clipboard

PUBLIC SERVICES FACILITY
5005 HARVEY ROAD
SPILL RESPONSE POLICY
AND
SPILL/RELEASE INCIDENT
REPORTING FORMS

Spill Response Plan
Public Services Facility `
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The Jamestown Public Services Facility located at 5005 Harvey Rd. is shown above. The site was
developed prior to stormwater rules, and much of the site's infrastructure does not appear on archived
site plans. Generally, water sheetflows towards the existing tributary to the Deep River which is on -site.
Any known site plans are attached to this sheet.
MSDS sheets, PPE, and Spill Response kits can be found at the office located on site.

Spill Response Policy
Public Services Facility
Purpose to protect storm water by educating employees on proper spill cleanup
procedures, state reporting requirements and preventative actions.
Always:
Call 911 immediately if you don't have control over the spill, if there is a
hazardous material involved, or if a significant health and safety hazard exists
(flammability, injury, etc.)
• Stop the source of the spill
• Contain any liquids
• Contact Operations Manager, Jeff Greeson 336-669-7396 or Public Services
Director, Paul Blanchard at 336-669-7398
• Cover the spill with absorbent material such as kitty litter, sawdust, or oil
absorbent pads. Do not use straw. Dispose of absorbent material properly.
• Use water only when necessary and minimize use.
• Fit petroleum and chemical storage containers with secondary containment
structures.
• Keep a spill kit in areas where petroleum or hazardous materials are stored.
• Train employees in spill response procedures and equipment.
• Position mats to contain drips from equipment or vehicles until they can be
repaired.
Never:
• Never wash a spill into the storm drain or a water body.
• Never leave a spill without cleaning it up.

Spill/Release Incident Reporting Form
Town of Jamestown
Pollution Prevention/Good Housekeeping Program
1. Date of spill/release:
2. Location:
3. Time of spill/release:
4. Material spilled/released:
5. Amount spilled/released:
6. Cause of spill/release:
a.m. / p.m.
7. Description of scene (e.g. type of media contaminated (e.g. soil), distance to storm
sewers, if spill/release was contained):
8. Description of clean-up actions taken (e.g. how spill/release was contained (e.g.
absorbent pillows), where recovered material was places, how much material was not
recovered, remaining action to be taken):
9. List of offsite emergency responders contacted:
10. List of offsite emergency responders at scene: '
11. Action taken to prevent
recurrence:
12. Signature:
Printed name:

Spill/Release Incident Reporting Form
Town of Jamestown
Pollution Prevention/Good Housekeeping Program
1. Date of spill/release:
2. Location:
3. Time of spill/re
4. Material spilled/released:
5. Amount spilled/released:
6. Cause of spill/release:
a.m. / p.m.
7. Description of scene (e.g. type of media contaminated (e.g. soil), distance to storm
sewers, if spill/release was contained):
8. Description of clean-up actions taken (e. g. how spill/release was contained (e.g.
absorbent pillows), where recovered material was places, how much material was not
recovered, remaining action to be taken):
9. List of offsite emergency responders contacted:
10. List of offsite emergency responders at scene:
11. Action taken to prevent
recurrence:
12. Signature:
Printed name:

Spill/Release Incident Reporting Form
Town of Jamestown
Pollution Prevention/Good Housekeeping Program
1. Date of spill/release:
2. Location:
3. Time of spill/release:
4. Material spilled/released:
5. Amount spilled/released:
6. Cause of spill/release:
a.m. / p.m.
7. Description of scene (e.g. type of media contaminated (e.g. soil), distance to storm
sewers, if spill/release was contained):
8. Description of clean-up actions taken (e. g. how spill/release was contained (e.g.
absorbent pillows), where recovered material was places, how much material was not
recovered, remaining action to be taken):
9. List of offsite emergency responders contacted:
10. List of offsite emergency responders at scene:
11. Action taken to prevent
recurrence:
12. Signature:
Printed name: