Northwest Region | Environmental incident report form (ERTS) | Washington State Department of Ecology, environmental problem, spills reporting

Washington State Department of Ecology

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Environmental Incident Report Form Northwest Regional Office (Island, King, Kitsap, San Juan, Skagit, Snohomish, and Whatcom counties) Report all oil and hazardous materials spills: You must call the TWO (2) following 24-hour numbers: 1) Washington Emergency Management Division: (including Emergency Release Notification) 1-800-258-5990 -OR- 1-800-OILS-911 AND 2) National Response Center: 1-800-424-8802 > Ecology Northwest Regional Office: 1-425-649-7000 > More about reporting spills... Other environmental incidents may be reported using the electronic form below. Please fill-in as much of the following information as you can. Please check it for accuracy and then click the "Submit" button at the bottom of this form. You may be contacted for additional clarification.
Information About You
Your First Name
Your Last Name
Your Business Name (if any)
Your Street Address
Your Apartment Number (if any)
Your City
Your State
Your ZIP Code
Your Home phone
Your Work phone
Your Email
Confidential?	If you indicate "Yes", your name, etc. will be kept confidential.

Description of Incident - What Happened
Date of Incident	(mm/dd/yyyy)
Medium
Material
Other Material
Quantity
Unit of Measure
Source
Cause
Activity
Impact
Vessel Name
Vessel Type
Additional Description of Incident

Location of Incident - Where did it happen
County
Nearest City
Street Address
Waterway
Waterway type
Directions

Potentially Responsible Party Information - Who is responsible
First Name
Last Name
Business (if any)
Street Address
Apartment or Suite (if any)
City
State
ZIP Code
Phone	Phone type:
Other Information about Potentially Responsible Party
To save your own record of the information entered above, please print this page before you hit the submit button below.

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Environmental Incident Report Form Northwest Regional Office

Report all oil and hazardous materials spills:

**To save your own record of the information entered above, please print this page before you hit the submit button below.**

Environmental Incident Report Form
Northwest Regional Office

To save your own record of the information entered above, please print this page before you hit the submit button below.