WA Dept. of Ecology environmental incident report form

Washington State Department of Ecology

Environmental Incident Report - Southwest Regional Office Report all oil and hazardous materials spills to: National Response Center: 1-800-424-8802 and Washington Emergency Management Division: 1-800-258-5990 or 1-800-OILS-911 and Ecology Southwest Regional Office: 1-360-407-6300 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

Environmental Incident Report - Southwest Regional Office