:: NATIONAL RESPONSE CENTER ::
::  STORAGE TANK REPORT (HTML)  ::

NOTE:  These Forms should NOT be submitted to the NRC via fax or mail. They were created for use in Training

and/or Response Plans, or to use as a guide when contacting the NRC.   

Fields displayed in RED and with an * are mandatory entries.  Please fill out the form as completely as possible.  

* Is this a DRILL Report ?       YES  NO

* 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:             

Are you calling on behalf of responsible party:

Yes  No

Are you or your company responsible for Material released:  

Yes  No

INCIDENT DESCRIPTION

* Description of Incident: 

* Incident Date:    * Time:      * Occurred/Discovered/Planned: 

Type of Incident:  STORAGE TANK

* Incident Cause: 

INCIDENT 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 #1
* Material:       CHRIS Code:          CAS Code: 

* Amount Released:    * Units:    Amount in Water:    Units: 

MATERIAL #2
Material:       CHRIS Code:          CAS Code: 

Amount Released:    Units:    Amount in Water:    Units: 

MATERIAL #3
Material:       CHRIS Code:          CAS Code: 

Amount Released:    Units:    Amount in Water:    Units: 

MATERIAL #4
Material:       CHRIS Code:          CAS Code: 

Amount Released:    Units:    Amount in Water:    Units: 

MATERIAL #5
Material:       CHRIS Code:          CAS Code: 

Amount Released:    Units:    Amount in Water:    Units: 

MATERIAL IN WATER INFORMATION

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:           
Number to Hospital:       
Rail Employee Injuries: 
Rail Passenger Injuries:

Fatalities:

Yes  No  Unknown

Number of Fatalities:     
Employee Fatalities:      
Passenger Fatalities:    
Vehicle Fatalities:         

Evacuations:

Yes  No  Unknown

Number Evacuated:      
Radius/Area in Miles:   
Who was Evacuated:    

Damages:

Yes  No  Unknown

Damage in Dollars:       

Road Closed:

Yes  No  Unknown

Road:                            
Major Artery:                    Yes    No
Hours Closed:              
Direction of Closure:     

Track Closed:

Passengers Transferred:

Yes  No  Unknown

Yes  No  Unknown

Track:                         
Hours Closed:            
Direction of Closure:  

Air Corridor Closed:

Yes  No  Unknown

Air Corridor:                
Hours Closed:             

Waterway Closed:

Yes  No  Unknown

Waterway:                   
Hours Closed:             

Environmental Impact:

Yes  No Unknown

Type of Impact:      

 

Media Interest:             

WEATHER INFORMATION

Weather Conditions:                       Air Temperature:            

Wind Speed:           Unit:          Wind Direction:    

REMEDIAL ACTION INFORMATION

Remedial Action Taken:  

Release Secured:   Yes  No  Unknown      Release Duration:      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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