Figure 1-Information on discharge *
[Involved Parties]
(A) Reporting party | (B) Suspected responsible party |
Name | Name |
Phones () - | Phones () - |
Company | Company |
Position | Organization Type: |
Address | Private citizen |
Address | Private enterprise |
Public utility | |
Local government | |
State government | |
Federal government | |
City | City |
State | State |
Zip | Zip |
* It is not necessary to wait for all information before calling NRC. National Response Center-1-800-424-8802 or direct telephone: 202-267-2675.
Were materials Discharged (Y/N)? |
Calling for Responsible Party (Y/N) |
Incident Description |
Source and/or Cause of Incident |
Date - - Time: |
Cause |
Incident Address/Location Nearest City |
Distance from City |
Storage Tank Container Type-Above ground (Y/N) Below ground (Y/N) Unknown |
Facility Capacity |
Tank Capacity |
Latitude Degrees |
Longitude Degrees |
Mile Post or River Mile |
Materials |
Discharge Unit of Quantity Measure Discharged Material Quantity in Water |
Response Action |
Actions Taken to Correct or Mitigate Incident |
Impact |
Number of Injuries Number of Fatalities |
Were there Evacuations (Y/N/U)? Number Evacuated |
Was there any Damage (Y/N/U)? Damage in Dollars |
Additional Information |
Any information about the Incident not recorded elsewhere in the report |
Caller Notifications |
USCG EPA State Other |
33 C.F.R. §154.1035