Pipeline Rupture Environmental Corrective Action Report

1. Basic Information

Date of Report Reported By Pipeline Name or ID Location Date and Time of Incident

2. Incident Description

Description of Pipeline Rupture Estimated Volume Released Material Released Immediate Actions Taken

3. Impact Assessment

Affected Areas (soil, water, vegetation, etc.) Potential or Observed Environmental Impacts

4. Corrective Actions

Corrective Actions Implemented Corrective Actions Planned Responsible Persons

5. Regulatory Notification

Agencies Notified Date and Time of Notification Reference Numbers / Case Numbers

6. Monitoring and Follow-up

Monitoring Activities Follow-up Actions Required

7. Attachments

List of Attachments (photos, maps, laboratory results, etc.)

8. Sign-off

Prepared By Date Reviewed By Date