Virden District Office

Economic Development,	Box 1359
Investment, Trade and Natural Resources	Virden MB R0M 2C0

_______________________________________________________________________________

Spill No.	Spill Location:	Spill Date:

Well Licence #:	GPS Co-ord (NAD 83):	Northing:	Easting:

Operating Company:

Reported By:	Date Reported:

Fluid Type (m3): Oil	Water	Other

Fluid Volumes (m3): Spilled:	Recovered:	Lost:

Spill Source:	Spill Cause:

Battery Operating Permit No.:	Flow Line License:	Segment No.:

Area Affected: m2	Spill Off Lease:

_____________________________________________________________________________

Sketch of Spill Area
(indicate approximate distances):	Landowner/Occupant:

Address:

Date Notified:

_______________________________________________________________________________

Action Taken By Company To:

Control Spill:

Date Completed:

Clean Up Spill Area:

Date Completed:

Disposition of Spill Fluids and Contaminated Material:

Date Completed:

Prevent Recurrence of Spill:

Date Completed:

Immediate Rehabilitation:

Date Completed:

Name of Person Completing Report:	Position in Company:

Date Form Completed:

For Department Use Only (DO NOT USE THIS AREA):

Spill Identification Level:	1	2	3

Inspected By:	Initial Inspection Date:

Final Inspection Date:	Follow Up Required:

Approved Date:	Health Unit Notified:

Enter Into Rehab. Program: YES / NO	Rehab. No.:

Remarks: