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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:
PIPELINE
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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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PIPELINE DETAILS
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Pipeline
Type:
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DOT
Regulated: Yes
No Unknown
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Underwater:
Yes No
Covered/Marked:
Yes No
Unknown
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Above
or Below Ground: Above
Below
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MATERIAL INVOLVED
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MATERIAL
#1
*Material:
CHRIS Code:
CAS Code:
*Amount
Released:
*Units:
Amount in Water: Units:
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MATERIAL
#2
Material:
CHRIS Code:
CAS Code:
Amount Released:
Units:
Amount in Water:
Units:
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MATERIAL
#3
Material:
CHRIS Code:
CAS Code:
Amount Released:
Units:
Amount in Water:
Units:
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MATERIAL
#4
Material:
CHRIS Code:
CAS Code:
Amount Released:
Units:
Amount in Water:
Units:
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MATERIAL #5
Material:
CHRIS Code:
CAS Code:
Amount Released:
Units:
Amount in Water:
Units:
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MATERIAL IN WATER INFORMATION
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Body of Water
Affected:
Offshore: Yes
No
River Mile Marker:
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Tributary of:
Water Supply Contaminated: Yes
No Unknown
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Water
Temperature:
Units:
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Wave Condition:
Speed: Units:
Direction:
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SHEEN INFORMATION
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Sheen Length:
Units: Sheen
Width:
Units:
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Color:
Direction of Movement:
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Odor
Description:
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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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