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Sample Environmental Incident Report

An environmental incident form was completed for Mega Agro Livestock Farm Corporation regarding a paint spill. On November 3rd, 2022 at 9:00 AM, a skilled worker accidentally dropped a gallon of paint after the lid was left unsealed. This resulted in 3 liters of paint spilling onto the warehouse floor. The possible cause was that the lid was not fully sealed and the handle was not tightened enough. Interim measures include ensuring paint lids are sealed and handles are tightened after work hours, and posting reminders for workers.

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72 views1 page

Sample Environmental Incident Report

An environmental incident form was completed for Mega Agro Livestock Farm Corporation regarding a paint spill. On November 3rd, 2022 at 9:00 AM, a skilled worker accidentally dropped a gallon of paint after the lid was left unsealed. This resulted in 3 liters of paint spilling onto the warehouse floor. The possible cause was that the lid was not fully sealed and the handle was not tightened enough. Interim measures include ensuring paint lids are sealed and handles are tightened after work hours, and posting reminders for workers.

Uploaded by

khan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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ENVIRONMENTAL INCIDENT FORM

NAME OF ESTABLISHMENT: MEGA AGRO LIVESTOCK FARM CORPORATION


ADDRESS: AGORA LAPASAN, CAGAYAN DE ORO CITY
NAME OF MANAGING HEAD: MR. ROMEO KHO
NAME OF PCO: MR. RUBEN AWITEN
DATE OF INCIDENT: NOVEMBER 3, 2022
TIME OF INCIDENT: 9:00 AM

TYPE OF INCIDENT (PUT AN X MARK)


BREAKDOWN OF WATER TREATMENT PLANT
BREAKDOWN OF AIR POLLUTION CONTROL DEVICE
X RELEASE OF CHEMICALS TO ENVIRONMENT MEDIA
RELEASE OF HAZARDOUS WASTE TO ENVIRONMENT -
EXCEEDANCE TO EFFLUENT STANDARDS
EXCEEDANCE TO EMISSION STANDARDS
OTHERS (PLEASE SPECIFY)

DESCRIPTION OF INCIDENT:
Around 9:00 AM of November 3, 2022 while our skilled worker withdrew one (1) gallon Paint without
noticing that the lid cover was not totally sealed accidentally mishandled it which he eventually dropped
the paint to the floor resulting to the spill of the paint which directly spread out to the flooring of
warehouse.
ESTIMATED AMOUNT OF CHEMICALS, HAZARDOUS WASTE, EMISSIONS, AND/OR EFFLUENTS RELEASE TO THE
RECEIVING ENVIRONMENT: 3 liters out of 1 gallon paint
Estimated amount of untreated wastewater released: 30,000 L/day x 1 day/8 hrs operation= 3750 L/hr
(Note: operator will conduct hourly inspection. Thus estimated to be one hour continuous discharged of
untreated wastewater assuming it did not happened during his previous area checking).
The lid cover of the paint was unnoticeably found out to be
POSSIBLE CAUSE OF THE INCIDENT: left unsealed and the handle was not tightened enough to
carry the weight of one (1) gallon paint

INTERIM/CONTINGENCY MEASURES TO MITIGATE ANY POTENTIAL NEGATIVE IMPACTS


1. After working hours the skilled workers should make assurance that the paint lid covers must be
totally sealed and the handle must be tightened enough.
2. PCO and his named assistant must make a posting in any conspicuous place within the warehouse
to remind the skilled workers about their duties before leaving the workplace which include among
others.
2.1 The proper safekeeping of materials, equipment, tools and devices that was used during the
working hours.
COMPLETED BY: RUBEN AWITEN DATE: Nov. 4, 2022
(SIGNATURE OF PCO)

NOTED BY: ROMEO KHO DATE: Nov. 4, 2022


(SIGNATURE OF MANAGING HEAD)
Note: Corrective Actions to Prevent Recurrence, Estimated Amount of the Needed Recovery/ Repair/ Clean-up, and
Estimated Date of Completion for Any Needed Repairs should be reflected in the next submission of the SMR.

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