Facility Name:


Your Name: *


Your Title:


Email Address: *


Address (Line 1): *


Address (Line 2):


City: *


State/Province: *


Zip/Post: *


Country: *


Telephone: *


Fax:


Facility Type: *


Plant Name:


Is the spill contained or in open water?
Contained
Open Water

How thick is the contamination on top of water (indicate whether feet, inches, meters or millimeters)?


Age of spill (days/weeks/months):


Estimated volume of the zone contamination (in cubic feet or cubic meters):


Type of Water:
Saltwater
Freshwater
Contained Water
Other

If "other," please describe:


Salinity of water in %:


pH of water:


Alkalinity of water (in mg/L):


Temperature (air). Please indicate whether Farenheit or Celcius:


Temperature (water). Please indicate whether Farenheit or Celcius:


Source(s) of contamination; please describe ranges and types of compounds encountered):


Current range of TPH (Total Petroleum Hydrocarbons) in ppm:


Current range of PAH (Poly Aromatic Hydrocarbons) in ppm:


Current range of Benzene in ppm:


Current range of Toluene in ppm:


Current range of Ethylbenzene in ppm:


Current range of Xylene in ppm:


Total current BTEX (Benzene/Toluene/Ethylbenzene/Xylene) in ppm:


Current range of asphaltenes in ppm:


Current level of heavy metals in ppm:


C:N:P (Carbon:Nitrogen:Phosphorus) levels in ppm or mg/L (please specify which):


For open water or large contained spills, is a boat boom spraying system or aircraft available to spray application onto the contaminated water?
Yes
No
N/A

If yes above, which mechanical application is available?
Boat/Boom Spraying System
Aircraft/Aerial Spraying System
N/A

How often is it practical for you to mechanically spray and treat the water?
Daily
Weekly
Bi-Weekly

Do you have a portable spray rig system available for applications to the contaminated water? (for contained spills)
Yes
No
N/A

If you do not have one of the two application systems above, are you willing to set up such a mechanized application or system?
Yes
No
N/A

Please disregard this field. It is for tracking purposes.
Survey - Water Oil Spill