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2. Business Name
3. Phone
5. Facility Contact Name
6. Phone
8. Incident Address
9. City
11. State
12. Zip
13. Dun & Brad Number
15. Business Owner Name
17. Owner Address
19. State
20. Zip
21. Phone
23. Environmental Coordinator Name
24. Phone
26. Safety Coordinator Name
27. Phone
29. Chemical Released
31. CAS Number
32. Is Chemical on 302 List?

    1. Yes

    1. No
34. Is this a reportable release?

    1. Yes

    1. No
35. Has the NRC been notified?

    1. Yes

    1. No
37. Person Notifying NRC
38. Time
40. NRC Incident Number
41. Date of Release
43. Physical State Released
44. Quantity Released
46. What time was the release discovered?
48. What actions did the person take who discovered the release?
50. Was any private contractor contacted to handle the release?

    1. Yes

    1. No
51. If yes, who was the contractor?
53. What was the exact cause of the release?
55. What actions have been taken to prevent another release?
57. Who was working in the area when the release was discovered?
59. What actions did they take?

61. Attach the following to the report: Any known or expected acute or chronic health risks associated with the release and advice regarding medical attention for exposed individuals
    
    

62. Additional Attachments

64. CERTIFICATION: I CERTIFY UNDER THE PENALTY OF LAW, THAT I HAVE PERSONALLY EXAMINED AND AM FAMILIAR WITH THE INFORMATION SUBMITTED AND BELIEVE THE SUBMITTED INFORMATION IS TRUE, ACCURATE, AND COMPLETE.
    
    

66. First Name
67. Last Name
69. Date
    Date

    Date
70. Phone
71. Title
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73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit Submit and Print

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