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2. Facility Information
4. Facility Name*
5. Facility Street Address*
7. City*
8. State*
9. Zip Code*
11. Name of Person Completing Report Form*
12. Email Address*
16. Dates
18. Report Date*
19. Incident Date*
23. Report Information
25. Report Status*
    -- Select One --Additional InformationFollow-up ReportInitial Notification
26. Material Discharged*
28. Discharge Amount*
30. Type of Discharge

    1. Accidental Discharge
    2. Non Customary Batch Discharge
    3. Non Routine / Episodic Discharge
    4. Slug Discharge
    5. Slug Load
    6. Other (Explain Further)
31. If selecting other, explain the type of discharge:
33. Hazard Evaluation*

    1. Corrosive Hazard
    2. Fire Hazard
    3. Personal Safety (Toxicity)
    4. Other (No Hazard Expected)
    5. Other (Explain Further)
34. If selecting other, explain the type of discharge:
38. Incident Description
40. Explain Cause(s) Attributed to Incident*
42. Provide a Description of Corrective Measures*
44. Additional Agencies Contacted
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field