Wastewater Discharge Spill Report
Facility Name
Location of Spill
Date of Spill
Time of Spill
Duration of Spill (hours/minutes)
Estimated Volume Discharged (liters or gallons)
Material Discharged
Receiving Water or Location (if any)
Cause of Spill
Actions Taken
Observed or Potential Environmental Impact
Reported By
Date Reported
Additional Information