Chemical Release Follow-Up Notification Form | Kanawha Putnam Emergency Planning Commission

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120 3rd Avenue
South Charleston, WV 25303

T 304.414.3600

Chemical Release Follow-Up Notification Form

EPCRA Section 304

Full instructions are below the form. Please be sure to complete all questions.

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EPA Identification Number (12 digits): *

Facility Name:

Emergency Contact Name:

Contact Phone:

Incident Address:

City, State, and Zip Code

Incident Date

Month

Day

Year

County:

LEPC:

Time of Verbal Notification to 911 Center:

Incident # (NRC):

Chemical Released:

CAS Number:

Is Chemical Listed in 40 CFR 302 / 355?

Physical State Contained:

Quantity Released (in pounds):

Physical State Released:

Time of Release

Duration of Release

Days

Hours

Minutes

Environmental Contamination

Describe Action Taken

Anticipated Health Effects of Release

Acute/Immediate

Explain Acute / Immediate Effects

Chronic / Delayed

Explain Chronic / Delayed Effects

Advice Regarding Medical Attention Necessary for Exposed Individuals:

Contact WV Poison Control Center - 1-800-222-1222

Comments

CERTIFICATION: I certify under penalty of law that I have personally examined and am familiar with the information submitted and that it is true, accurate and complete.

Reporting Facility Representative Title

Reporting Facility Representative Name

Date of Report

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CHEMICAL RELEASE FOLLOW-UP NOTIFICATION FORM INSTRUCTIONS

Local emergency planning committee’s (LEPC) requires that Emergency Release follow-up notifications be submitted using this reporting form. Releases of reportable quantities of Extremely Hazardous Substances (EHS) (listed in 40 CFR 355, appendix A) or chemicals that require release reporting under section 103 (a) of the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) must be reported on the form within 14 days following a release. The written follow-up report is required in addition to immediate verbal notification.

BASIC INSTRUCTIONS:

The completed form satisfies the Emergency Planning & Community Right-to-Know Act Section 304 requirement. Ensure that all information is complete.
If the incident involves reportable releases of more than one chemical, prepare one report form for each chemical released.
If the incident involves a series of separate releases of chemical(s) at different times, the releases should be reported on separate reporting forms.

SPECIFIC INSTRUCTIONS: Enter the EPA Identification Number, the facility name, phone number, and name of a contact person who can provide detailed information concerning the incident.

Enter the date of the incident, the time that verbal notification was made to the Emergency Management 911 Center, and the National Response Center (NRC) incident number in the space provided.

Provide information about the location where the release occurred. Include the street address, city, state, zip code, county, local emergency planning committee, and if appropriate, provide information about bordering LEPCs or states.

Provide information concerning the specific chemical that was released. Include the chemical/trade name and the Chemical Abstract Service (CAS) number. Check all categories that apply. Provide best available information on quantity, time and duration of the release.

Indicate all actions taken to respond to and contain the release.

Check the categories that apply to the health effects that occurred or could result from the release. Provide an explanation or description of the effects in the space provided. Use the Comment section to provide additional pertinent information.

Include information on the type of medical attention required for exposure to the chemical release. Indicate when and how this information was made available to individuals exposed and to medical personnel, if appropriate for the incident.

List any additional pertinent information.

Print or type the name of the facility representative submitting the report. Include the official signature and the date that the form was prepared.

CALL COUNTY 911 Center: 911

CALL THE NATIONAL REPONSE CENTER: 1 800.424.8802

EMAIL COMPLETED REPORTS TO: Kanawha Putnam Emergency Planning Committee [email protected]