CLARK COUNTY DEPARTMENT OF AVIATION SPILL REPORT
The tenant is responsible for the clean-up and proper disposal of its spill. The tenant must immediately call the
Airport Control Center (702-261-5125). The tenant must complete this form in its entirety and return or FAX
(702-261-5096) a copy to the Department of Aviation within 24 hours of the spill. Refer to the Department of
Aviation Environmental Management System for more information on reporting and cleaning up spills.
PLEASE TYPE OR PRESS FIRMLY; IF EXTRA SPACE IS REQUIRED ATTACH AN ADDITIONAL PAGE TO THIS REPORT.
Person making report:
Company:
Responsible party for spill:
☐Jet A Fuel
Material Spilled:
Contact Phone #:
Date/Time of Spill:
☐Unleaded
Estimated Spill Quantity:
☐Diesel
☐Hydraulic Fluid
☐Gallons* ☐ Quarts
☐Blue Juice
Estimated Quantity recovered:
☐Air Cargo ☐A ☐B ☐C ☐D ☐E ☐Gate:
Location of Spill:
Date/Time Spill Clean-up Completed:
Other:
☐Gallons* ☐ Quarts
☐Atlantic ☐Signature ☐Holding Pad#
☐RON ramp ☐Taxiway ☐Runway ☐Other:
Source:
☐Commercial Aircraft ☐Private Aircraft ☐Hydrant System ☐P-cart ☐Fuel truck ☐Lavatory vehicle
☐Other:
Aircraft registration Number
Fueling vehicle permit number:
Other:
1. Cause and circumstance of spill:
2. What is being done to ensure that such a spill will not recur?
3. Were proper clean up procedures used:
☐Yes
☐No
4. Source of clean up materials:
5. Type of absorbent material or devices used:
☐Granular Absorbent ☐Booms ☐Socks ☐Pads ☐Other:
6. Method and location of disposal of absorbent material or devices:
7. Unusual circumstances or other pertinent data:
Signature:
Date:
Email:
*
If any spill is 25 gallons or more, the tenant is responsible for contacting the Nevada Division of Environmental
Protection at 888-331-6337 within the next business day following the spill.
NDEP Report number:
(Required for spills 25 gallons or more only)
FAX or Send copy to:
DOA Environmental Section
P.O. Box 11005
Las Vegas, NV 89111
Call (702) 261-5125
FAX (702) 261-5096
Safety Environmental
Copy
Reporting Agency
MIA Only – Spill Report
Copy
Responsible Party
Revised: 01/20/2016