Report Spills to the NRC at: 1-800-424-8802
 
REPORTING PARTY SUSPECTED RESPONSIBLE PARTY
Last Name: Last Name:
First Name: First Name:
Phone: Phone:
   
Company: Company:
Position: Position:
Address: Address:
   
City: City:
State/ZIP: State/ZIP:
 
Were materials released ?Yes No Request Caller Confidentiality ? Yes No
Meeting Federal Requirements by Calling for Responsible Party ? Yes No
 
INCIDENT SOURCE AND CAUSE
Source/Cause:
Date: _______Time: _______ Occured Discovered 
 
Type:Air Fixed Facility Highway Marine Offshore Offshore Unknown Pipeline Grade Crossing Railroad Unknown 
 
Cause:Dumping Equipment Failure Natural Phenomenon Operator Error Transport Accident Unknown 
 
Railroad Hotline ?: Yes No Vessel/Vehicle Number:
Continuous Release Type: Continuous Release #: 
 
INCIDENT LOCATION
Incident Address/Location: Nearest City:
State: County/ZIP:
Distance from City: Direction from City:
Section: Township:______Range:____
Container Type:____Capacity:____ Facility Capacity:
Latitude: Longitude:
Offshore Area ID:____Block:____ Milepost:
 
MATERIAL INVOLVED
Chris Code________Amt____Unit_____Material Name________________________________Amt in Water____Unit____
Chris Code________Amt____Unit_____Material Name________________________________Amt in Water____Unit____
Chris Code________Amt____Unit_____Material Name________________________________Amt in Water____Unit____
Chris Code________Amt____Unit_____Material Name________________________________Amt in Water____Unit____
Chris Code________Amt____Unit_____Material Name________________________________Amt in Water____Unit____
Chris Code________Amt____Unit_____Material Name________________________________Amt in Water____Unit____
 
REMEDIAL ACTION
Actions Taken:
 
Air Corridor Closed ?: Yes No Roads Closed ?: Yes No
Number of Injuries: Number of Fatalities:
Evacuations ?: Yes No Number Evacuated:
Damage ?: Yes No Damage in Dollars:
Medium Affected:
 
CALLER NOTIFICATIONS

Environmental Protection Agency US Coast Guard State Agency Other

NRC REPORT NUMBER #:
This number is assigned by an NRC Duty Officer upon receipt of the report.