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  • Hazardous Materials Emergency Release Notification Report

    To report a Hazardous Materials release, complete this form
    Hazardous Materials Incident Report Form

    Company & Notification Information

    1. Company Name:  

    2. Address Where Release Occurred:  

    3. NRC#:  

    4. Method of Notification:   5. Date of Incident:  

    6. Action Taken to Respond and Contain the Release:  

    7. Facility Emergency Coordinator (Name):  

    8. Telephone Work:   Telephone Cell:

    Chemical Release Information

    9. Chemical Name(s):   10. CAS#:  

    11. Extremely Hazardous Substance:         12. Substance State:   

    13. Estimated Quantity Released:   

    14. Duration of Release: : (HH:MM)

    15. Release Time Start:  : (HH:MM) AM PM

    16. Release Time Stop:  : (HH:MM) AM PM

    17. Medium Into Which Release Occurred (check all that apply):     Other:

    Risk Management

    18. Known Acute or Chronic Health Effects of Chemical:

    19. Medical Advice for Exposed Individuals:  

    20. Precautions Taken to Lessen Exposure:

    21. Evacuation:      If Yes, Distance:  

    22. Weather Conditions   Temperature (°F) Wind Direction:   Speed (MPH):

    23. Forecast:  

    24. Additional Information:


    Completed By:    Department:  


    Referred from Page: 

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