Attachment_3_EmergencySpillForm.pdf

AG-03R6-S-13-0024 Attachment 3

Emergency Spill Report

Enter Name of National Forest: _______________________________

Spill Information and Reporting Form

1. Name of individual reporting spill:

2. Phone Number:

3. Date and Time of Release/Discovery:

4. Date and Time Reported:

5. Duration of Release:

6. Location: (Include state, county, route, milepost, etc):

7. Chemical Name:

8. Chemical Identification Number:

9. Other Chemical Data:

Note: for transporation released incidents, this information may be available from the driver, placards on the vehicle, &/or shipping paper.

10. Noted characteristics of release (i.e., smell, fumes, etc.)

11. Known Health Risks:

12. Appropriate precaustion if known:

13. Source and cause of release:

14. Number and type of injuries:

15. Potential threat to health and environment:

16. Estimate of quantity released: Gallons:

17. Quantity reaching water: Gallons:

18. Name of affected watercourse and distance to source of spill:

19. For transportation incident, name and address of carrier:

20. Railcar of truck number: