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Please fill out the form as completely as possible.  Fields 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:  STORAGE TANK                   Incident Cause: 

ACCIDENT LOCATION
Location Description:
Address Location:
 		 State:     

County:   

ZIP:       

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

TANK/CONTAINER  DETAILS
Tank/Container Description:    Tank/Container  ID: 
Above/Below Ground:    Above  Below Transportable:   Yes  No  Unknown
Regulated:   Yes  No  Unknown Regulated by: 
Tank/Container Capacity:      Amount in Tank:   

MATERIAL INVOLVED

Material

Chris Code

Release Amount

Units

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 Temperature:   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 Information:

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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