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Fields displayed in RED and with an * are mandatory entries. Please
fill out the form as completely as possible.
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* Is this a DRILL Report ?
YES
NO
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* E-Mail Address:
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REPORTING PARTY
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SUSPECTED RESPONSIBLE PARTY
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* Phone 1: Type:
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* Last Name:
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* Last Name:
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First
Name:
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First
Name:
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Phone
1:
Type:
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Phone
2: Type:
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Phone
2:
Type:
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Phone
3: Type:
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Phone
3:
Type:
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Company:
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Company:
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* Org Type:
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* Org Type:
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Address:
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Address:
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City:
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City:
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* State:
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* State:
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ZIP:
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ZIP:
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Are
you calling on behalf of responsible party:
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Yes
No
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Are you
or your company responsible for Material released:
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Yes
No
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INCIDENT DESCRIPTION
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* Description of Incident:
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* Incident Date:
* Time:
* Occurred/Discovered/Planned:
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Type
of Incident:
CONTINUOUS RELEASE
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* Incident Cause:
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INCIDENT LOCATION
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* Location Description:
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* Address Location:
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* State:
* County:
ZIP:
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Nearest
City:
Distance from Nearest City:
Units:
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Direction:
Range:
Section: Township:
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Latitude:
Degrees:
Minutes:
Seconds:
Quadrant:
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Longitude:
Degrees:
Minutes:
Seconds:
Quadrant:
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CONTINUOUS RELEASE DETAILS
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* Release Type:
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Initial
Number:
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Permit
Number:
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Begin
Date:
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End
Date:
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Change
Date:
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FIXED INCIDENT LOCATION DETAILS
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Facility
Name/ ID:
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FIXED INCIDENT DESCRIPTION DETAILS
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* Fixed Object / Facility Type:
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Power
Generating Facility: Yes No
Unknown
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Compliance
with NPDES Permits: Yes No
Unknown
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CONTINUOUS RELEASE MATERIALS
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CHRIS Code: (Use
UNK if not known) CAS Number:
* Name of Material:
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Upper
Bounds:
Upper Bounds Unit:
Upper Bounds Rate:
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CHRIS
Code: (Use UNK if not known)
CAS Number:
Name of Material:
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Upper
Bounds:
Upper Bounds Unit:
Upper Bounds Rate:
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CHRIS
Code: (Use UNK if not
known)
CAS Number:
Name of Material:
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Upper
Bounds:
Upper Bounds Unit:
Upper Bounds Rate:
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CHRIS
Code: (Use UNK if not
known)
CAS Number:
Name of Material:
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Upper
Bounds:
Upper Bounds Unit:
Upper Bounds Rate:
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CHRIS
Code: (Use UNK if not
known)
CAS Number:
Name of Material:
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Upper
Bounds:
Upper Bounds Unit:
Upper Bounds Rate:
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IMPACT INFORMATION
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Medium Affected:
Detailed Medium Information:
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Fire:
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Yes
No Unknown
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Fire
Extinguished: Yes No
Unknown
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Injuries:
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Yes
No Unknown
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Number
of Injuries:
Number to Hospital:
Rail Employee Injuries:
Rail Passenger Injuries:
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Fatalities:
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Yes
No Unknown
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Number
of Fatalities:
Employee Fatalities:
Passenger Fatalities:
Vehicle Fatalities:
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Evacuations:
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Yes
No Unknown
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Number
Evacuated:
Radius/Area in Miles:
Who was Evacuated:
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Damages:
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Yes
No Unknown
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Damage
in Dollars:
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Road
Closed:
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Yes
No Unknown
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Road:
Major
Artery:
Yes No
Hours
Closed:
Direction of Closure:
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Track
Closed:
Passengers
Transferred:
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Yes
No Unknown
Yes
No
Unknown
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Track:
Hours
Closed:
Direction of Closure:
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Air
Corridor Closed:
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Yes
No Unknown
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Air
Corridor:
Hours Closed:
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Waterway
Closed:
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Yes
No Unknown
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Waterway:
Hours Closed:
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Environmental
Impact:
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Yes
No Unknown
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Type
of Impact:
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Media
Interest:
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WEATHER INFORMATION
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Weather
Conditions:
Air
Temperature:
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Wind
Speed:
Unit: Wind
Direction:
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REMEDIAL ACTION INFORMATION
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Remedial
Action Taken:
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Release
Secured: Yes
No Unknown Release
Duration:
Unit:
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Rate
of Release:
Unit:
Per:
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ADDITIONAL AGENCY INFORMATION
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Federal
Agency Notified:
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State/Local
Agency Notified:
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State/Local
Agency On-Scene:
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State
Agency's Report Number:
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ADDITIONAL INFORMATION
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Additional
Information:
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