Laserfiche WebLink
THIS FORM PROVIDES <br />GUIDANCE FOR INITIAL NOTIFICATION <br />THIS FORM PROVIDES GUIDANCE FOR INITIAL NOTIFICATION <br />EMERGENCY PLANNING .-%ND COMMUNITY RIGi IT -TO -KNOW ACT <br />SI C" ION' 3(74 REPORTING FORN4 <br />Reporting Number 8501413.9911 <br />1. General Information SARA LOG <br />B. Reported by (Name/Company) <br />C. Contact Person (If different from 1-13 above) <br />D. Location <br />E. Telephone Number <br />2. Release Information <br />A. Substance(s) Involved <br />B. Release Nlediuna Air Water (su ace/ground) Lan <br />C. Event Terminated: Yes No <br />Release Began Ended Duration <br />D. Quantity Released <br />E. EI -IS Release Yes/No; CERCI A Release: eigc%/No <br />3. Is this a Reportable Incident/Emergency under Section Y43 <br />4. Incident Description: <br />5. Action Taken to Respond or Contain: <br />d. Potential Health Risk (If known or anticipated) <br />A. Off-site <br />B. Injures: Release Related/Number <br />Non -Release Related/Number <br />7. Recommended Protective Actions (Where Appropriate, Advise Regarding Attention <br />Necessary for Exposed Individuals) <br />8. _Aaencies Notified by IndUStry <br />A. County E.M. D. State DFP <br />B. Local F.D. E. Other <br />C. Local Environmental <br />9. Emereencv Assistance Reouested: Yes/No; If Yes: <br />A. Local F.D. E. Local Health <br />B. County E.M. F. State DEP <br />C. Local Environmental G. other <br />D. Local Law Enf. <br />10. Should More Than 15 Minutes Difference Exist Between Release Beginning Time ( } <br />and Reporting Time Explain <br />Reason for Not Immediately Reporting the Incident: <br />11. Message Reeei%,A Bay: Name Time Date <br />'I'IIIS wi."s \OT F'i I.l II:I: 'I'1II; REQiiIREME--,TS 'S FOR :1 FOLLOW -1-1) REPORT. <br />Indian River County Emergency Plan for Hazardous Materials Page 34 <br />