Read NRC PDF Report Forms - PIPELINE REPORT text version

:: NATIONAL RESPONSE CENTER :: :: PIPELINE REPORT (PDF) ::

The PDF Report should not be submitted to the NRC via fax or mail. They were created for use in Training and/or Response Plans, or as a guide when contacting the NRC. Please file reports via our toll-free number (800-424-8802) or by submitting an ONLINE REPORT.

Fields displayed in RED are mandatory entries. Please fill out the form as completely as possible. E-Mail Address:

Is this a DRILL Report ?

YES

NO

REPORTING PARTY

Phone 1: Last Name: First Name: Phone 2: Phone 3: Company: Org Type: Address: Type: Type: Type:

SUSPECTED RESPONSIBLE PARTY

Last Name: First Name: Phone 1: Type: Type: Type:

Phone Type

Phone Type Phone Type Phone Type

Phone Type Phone Type

Phone 2: Phone 3: Company:

Organization Type

Org Type: Address:

Organization Type

City: State: ZIP: Are you calling on behalf of responsible party: Are you or your company responsible for Material released:

City:

Choose State

State: ZIP: Yes Yes

Choose State

No No

INCIDENT DESCRIPTION

Description of Incident:

Incident Date:

Day

Month

2007

Time:

Occurred/Discovered/Planned:

Choose ODP

Type of Incident: PIPELINE

Incident Cause:

Choose Cause

INCIDENT LOCATION

Location Description:

State: Address Location: County:

Choose State

ZIP: Nearest City: Direction: Latitude: Distance from Nearest City: Range: Seconds: Seconds: Section: Units: Township: Quadrant: Quadrant:

Choose Unit

Choose Direction

Degrees:

Minutes: Minutes:

Choose Quadrant Choose Quadrant

Longitude: Degrees:

PIPELINE DETAILS

Pipeline Type: Underwater:

Choose Pipeline Type

Yes No

DOT Regulated:

Yes

No Above

Unknown Below

Above or Below Ground:

Covered/Marked:

Yes

No

Unknown

MATERIAL INVOLVED

MATERIAL #1 Material: CHRIS Code: CAS Code:

Amount Released: MATERIAL #2 Material:

Units:

Choose Unit

Amount in Water:

Units:

Choose Unit

CHRIS Code:

CAS Code:

Amount Released: MATERIAL #3 Material:

Units:

Choose Unit

Amount in Water:

Units:

Choose Unit

CHRIS Code:

CAS Code:

Amount Released: MATERIAL #4 Material:

Units:

Choose Unit

Amount in Water:

Units:

Choose Unit

CHRIS Code:

CAS Code:

Amount Released: MATERIAL #5 Material:

Units:

Choose Unit

Amount in Water:

Units:

Choose Unit

CHRIS Code:

CAS Code:

Amount Released:

Units:

Choose Unit

Amount in Water:

Units:

Choose Unit

MATERIAL IN WATER INFORMATION

Body of Water Affected: Tributary of: Water Temperature: Wave Condition: Units: Offshore: Yes No River Mile Marker: Yes No Unknown

Water Supply Contaminated:

Choose Unit

Speed: Units:

Choose Condition

Choose Unit

Direction:

Choose Direction

SHEEN INFORMATION

Sheen Length: Color: Odor Description: Units:

Choose Unit

Sheen Width:

Units:

Choose Unit

Choose Color

Direction of Movement:

Choose Direction

IMPACT INFORMATION

Medium Affected: Fire: Injuries:

Choose Medium

Detailed Medium Information: Yes Yes No No Unknown Unknown Fire Extinguished: Number of Injuries: Number to Hospital: Rail Employee Injuries: Rail Passenger Injuries: Yes No Unknown

Fatalities:

Yes

No

Unknown

Number of Fatalities: Employee Fatalities: Passenger Fatalities: Vehicle Fatalities:

Evacuations:

Yes

No

Unknown

Number Evacuated: Radius/Area in Miles: Who was Evacuated:

Choose Who was Evacuated

Damages: Road Closed:

Yes Yes

No No

Unknown Unknown

Damage in Dollars: Road: Major Artery: Hours Closed: Direction of Closure: Yes No

Choose Closure Direction

Track Closed: Passengers Transferred

Yes

No

Unknown

Track: Hours Closed:

Yes

No

Unknown

Direction of Closure:

Choose Closure Direction

Air Corridor Closed:

Yes

No

Unknown

Air Corridor: Hours Closed:

Waterway Closed:

Yes

No

Unknown

Waterway: Hours Closed:

Environmental Impact:

Yes

No

Unknown

Type of Impact: Media Interest:

Choose Type of Impact Choose Media Interest

WEATHER INFORMATION

Weather Conditions: Wind Speed: Unit:

Choose WX Choose Unit

Air Temperature: Wind Direction:

Choose Unit Choose Wind Direction

REMEDIAL ACTION INFORMATION

Remedial Action Taken:

Release Secured: Rate of Release:

Yes

No Unit:

Unknown

Release Duration: Per:

Unit:

Choose Rate

Choose Unit

Choose Rate

ADDITIONAL AGENCY INFORMATION

Federal Agency Notified: State/Local Agency Notified: State/Local Agency On-Scene: State Agency's Report Number:

ADDITIONAL INFORMATION

Additional Information:

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Copyright © 2007, National Response Center

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NRC PDF Report Forms - PIPELINE REPORT

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