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<br />Date: Time: <br />I. GENERAL INFORMATION (also see Oil and Hazardous Substance Release Report) <br />A. Incident Name: <br />Refining: 0 Barge: 0 Railroad: 0 Pipeline: 0 Truck: 0 <br />B. Location: <br />Nearest Intersecting Roadways: <br />State: County: Township: <br />C. Entry Objectives - the objectives ofthe initial entry to the contaminated areas are <br />to: (describe actions, tasks to be accomplished; i.e.; identify contaminated soil, monitor <br />conditions, etc.): <br /> <br />II. PERSONNEL ORGANIZATIONS (include all shifts as necessary) <br />A. Senior Manager: <br />B. Incident Commander: <br />C. Deputy Incident Commander: <br />D. QA/QC Officer: <br />E. Legal Officer: <br />F. Safety Officer: <br />G. Deputy Incident Commander: <br />H. Operations Section Chief: <br />I. Planning Section Chief: <br />1. Logistics Section Chief: <br />K. Finance Section Chief: <br />L. Contractor A: <br />M. Contractor B: <br />N. Contractor C: <br />O. Contractor D: <br />III. SITE ORGANIZATION AND CONTROL <br />A. Command Area: <br /> <br />B. Staging Area: <br />C. Site Security and Access Points: <br />D. Work Area Identified: <br />Hot (Exclusion) Zone: <br />Warm (Contamination Reduction) Zone: <br />Cold (Support) Zone: <br />E. Decontamination Area: <br />F. Additional areas that are related to this incident are located: <br />(areas which are separate and/or remote may need individual site plan) <br /> <br />IV. SITE DESCRIPTION <br />A. General: <br />Release is on: 0 land, 0 water, or 0 both. <br />B. Unusual Site Features: <br />o Uneven terrain 0 Steep grades 0 High altitude <br />o Dense forest/timber 0 Heavy underbrush 0 Swampslbogs <br />C. Map/Sketch of site available and attached: 0 Yes 0 No <br />D. Land is used for: <br />o Agricultural 0 Industrial 0 Residential 0 Recreational <br />E. Ecological Considerations: Are any of the following near this site: <br />o Public water intakes 0 Private Wells 0 Streams 0 Ponds/Lakes <br />o Nature Preserves 0 Fish/Wildlife Areas 0 Endangered Species <br />o Parks/Recreation Areas 0 Historical/Archaeology Areas <br />Comments: <br />V. SITE HAZARD ASSESSMENT <br /> <br />28 <br />