# Emergency Response and Training Solutions Incident Response Form ERTS Project # 09162009DIPA2602 ERTS Ticket # 2602 Customer Claim # Pre-Assessment Date 9/17/09 Time 1400 EST Project Manager Aal’on

### Wickham Incident Reported by Dan Chimino of Halliburton
- Company Contact Person Information: Phone number:

### 724-541-6053 x Fax Number: E-mail: 

### daniel.chimino@halliburton.com Additional: Incident occurred: [~ In transit (over the road, rail, etc.) [~ Clients’ facility [~ Clients’ customer facility

[~ Other (specify) ~ Date and time of release: 9/16/09

__ I~Unknown Date and time of Discovery: 9/16/09 1605 DATE TIME DATE TIME Location of incident: Cabot Oil & Gas, Troy Road, Dimock, Pennsylvania Initial incident description: Lubricant & water solution released into stream 

### Reported Quantity Released: 1200 Gallons Any injuries or evacuations? DYes [~No On site Contact Dan Chimino Affiliation Halliburton Phone number 724-541-6053 Onsite Contact Phone number If yes, describe Driver’s name Phone number Other Contact on site Affiliation Phone number Vehicle Information: [] Tractor-Trailer [] Cargo Tank [] Tank Car [] Other__ Tractor number Trailer number Unit number Container Type: [] Saddle Tank [] Tank [] Tote [] Drum []Other__ Size of container marked __ Performance Package Markings (i.e. UN1A/X1-8/25/96USA)_ Factors contributing to release: [] Equipment Failure [] Motor Vehicle Accident - [] Possible Shipper Error - [] Other__
Materials Involved: []Hazardous Proper Shipping Name: UN Proper Shipping Name: UN []Non-hazardous []Diesel fuel/oil HAZ Class PG RQ HAZ Class PG RQ [] Other
Significant Chemical Hazards/Risk: __ Is the MSDS Attached? Has the Bill of Lading been provided? Does the shipper require immediate notification? Is response contractor required? [] Yes [] No Contractor: Northridge []Yes []Yes []Yes [] Network []No



### []No []No [] Non-network [] DOT 5800.1 Form required as per 49 CFR 171.15 Comments__ Initial/Immediate Emergency Actions Taken: ERTS dispatched a network contractor to the site.



## HESI302993

### Regulatory Notifications

Agency [] NRC [] EPA [] State Environmental Agency [] State Emergency Management Agency Law Enforcement Agency [] Fire Department [] County LEPC Notified by Date Time Contact Case/Ref. No.

Additional Comments: 

### Post Assessment Release description: Re|ease impacted a sma|| ~tream and a wet|and area. Actual volume/amount of material released: ]200 Gallons
Surface water affected? []Yes Drain connected to sanitary sewer? []Yes Drain connected to storm sewer? []Yes []No []Potential Describe (If yes, Name of water body) ~ Length of affected area ~ Distance from spill location to surface water, in feet 

### []No (If yes, include name of wastewater treatment plant and/or street drain if known) __ []No (If yes, include number of drain or water body it discharges into, if known) __ Are there water wells, pipelines, phone lines, or utility lines that release might follow? []Yes []No (If yes, describe),~
Ground water affected Soil Contamination Fish Kill Wildlife affected Vegetation affected []Yes [~No []Potential Describe~ []Yes []No []Potential Describe~ []Yes [~No []Potential Describe~ []Yes [~No []Potential Describe~ []Yes []No []Potential Describe~ Specific area of release [] Roadway [] Shoulder [] Drain [] Parking area [] Inside Trailer []Dock [] Median [] Roadside ditch [] Other Surface Type []Soil []Asphalt []Cement []Gravel []Wood []Other Weather Conditions Injuries or exposures (to public/bystanders) Was anyone hospitalized? Is this a reportable incident? []Clear []Rainy []Hot []Cold [] Snow [] Icy []Other~ []Yes []No []Potential Describe ~ 

### []Yes []No If yes, number hospitalized? []Yes []No Explain~



## HES1302994Response Team Information

Contractor

### Northridge Group Contact Name Dave Ad dress City State __ Zip __ Phone number570-473-8238 Fax number E-mail: Amountand job description(s) of ERTS initially approved personnel responding tosite [] Supervisors/Foremen: 1 [] Technicians: [] Equipment Operators: Description of ERTS initially approved contractor equipment dispatched tosite 1 pickuptruck

PPE Level []Vapor concentration (ppm) Health and Safety Site monitoring (if applicable) ~ [] Oxygen level (%) _ [] LEL for chemical of concern exceeded



### Corrective Action 

### Corrective Action:On September 16, 2009, Northridge Group personnel arrived on site to provide technical assistance and oversight at the request of Daniel Chimino. Baker Tank personnel had already responded to the site and begun cleaning up the released product. Hay bales had been placed in the stream to form containment areas and the product was being vacuumed from these areas into a new frac tank. Rain in the area washed the lubricant product from the surrounding soil into the containment areas and aided the process. On September 17, 2009, Northridge Group personnel returned to the site and inspected the area. Baker Tank personnel had worked through the night and had nearly completed the cleanup.

Manifests attached Name of facility Date [--]Yes 

### Waste Disposal []No

Amount Contact name Add ress City __ State __ Zip __ Comment pendin,q


### Additional Information/Remarks



## HESI302995