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Please fill out the form as completely as possible.  Fields displayed in RED are mandatory entries.  
Is this a Drill Report ? YES  NO    Your E-Mail Address:

REPORTING PARTY

SUSPECTED RESPONSIBLE PARTY
Phone 1:       Type: Last Name: 
Last Name:  First Name: 
First Name:  Phone 1:        Type:
Phone 2:       Type: Phone 2:        Type:
Phone 3:       Type: Phone 3:        Type:
Company:     Company:     
Org Type:    Org Type:    
Address:      Address:      
                                            
City:             City:             
State:           State:           
ZIP:              ZIP:              
Does the caller wish to remain Confidential ?  Yes  No
Are you calling on behalf of responsible party ? Yes  No
Are you or your company responsible for the Material released ?   Yes No

INCIDENT DESCRIPTION
Description of Incident: 
 
Incident Date:    
                            (DD/MM/YY)		 Time:    Occurred/Discovered/Planned: 
Type of Incident:  CONTINUOUS RELEASE         Incident Cause: 

ACCIDENT LOCATION
Location Description:
Address Location:
  		State:     

County:   

ZIP:       
Nearest City:      Distance from City:  Units:
Direction:      Range:     Section:    Township: 
Latitude:     Degrees:     Minutes:     Seconds:      Quadrant: 
Longitude:  Degrees:    Minutes:     Seconds:      Quadrant: 

FIXED INCIDENT LOCATION DETAILS
Building ID: 

FIXED INCIDENT  DESCRIPTION DETAILS
Fixed Object / Facility Type:    
Power Generating Facility ?  Yes  No  Unknown
Compliance with NPDES Permits ?  Yes  No  Unknown

CONTINUOUS RELEASE DETAILS

Release Type:      Initial Number: 
Permit Number:  Begin Date:       
End Date:              Change Date:    

CONTINUOUS RELEASE MATERIALS

CHRIS Code:             CAS Number:       Name of Material: 
Upper Bounds:    Upper Bounds Unit:    Upper Bounds Rate: 
 
CHRIS Code:             CAS Number:        Name of Material: 
Upper Bounds:     Upper Bounds Unit:    Upper Bounds Rate: 
MATERIAL IN WATER INFORMATION

Amount in Water:  Units:

Body of Water Affected:

Offshore:  Yes  No

River Mile Marker:

Tributary of:

Water Supply Contaminated:  Yes   No  Unknown

Water Temp:   Units: 

Wave Condition: Speed:    Units:   Direction:

SHEEN INFORMATION

Sheen Length:    Units:    Sheen Width:    Units:

Color: 

Direction of Movement: 

Odor Description: 

 
IMPACT INFORMATION

Medium Affected:

Detailed Medium Info:

Fire ?

 Yes  No  Unknown Fire Extinguished ?  Yes  No  Unknown
Injuries ? Yes  No  Unknown Number of Injuries ?        
Fatalities ? Yes  No  Unknown Number of Fatalities ?      
Evacuations ? Yes  No  Unknown Number of Evacuations ? 
Damages ? Yes  No  Unknown Damage in Dollars:             
Road Closed ? Yes  No  Unknown Road:                                    
Track Closed ? Yes  No  Unknown Track:                                   
Air Corridor Closed ? Yes  No  Unknown Air Corridor:                       
Waterway Closed ? Yes  No  Unknown Waterway:                           
Community Impact Due to Material    Yes  No  Media Interest:            

WEATHER INFORMATION

Weather Conditions:              Air Temperature:   
Wind Speed:    Unit:  Wind Direction:    

REMEDIAL ACTION INFORMATION

Remedial Action Taken:  
Release Secured ?   Yes  No  Unknown        Duration of Release ?    Unit: 
Rate of Release ?    Unit:  Per: 

ADDITIONAL AGENCY INFORMATION

Federal Agency Notified: 
State/Local Agency Notified: 
State/Local Agency On-Scene: 
State Agency's Report Number: 

ADDITIONAL INFORMATION

Additional Information:

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