OPENING SEOO INCIDENT NUMBER (S)
______________________
EMERGENCY MANAGEMENT
STATE:_____________________
CLOSING SEOO HAZARDOUS MATERIALS INCIDENT WORKSHEET
______________________
LOCAL:_____________________
I N I T I A L I N F O R M A T I O N
1) DATE OPENED TIME OPENED TIME
OF OCCURRENCE DATE CLOSED TIME
CLOSED
/ / / / __ _________
mo. day
yr. 24 hr.
Clock 24 hr. Clock
mo. day
yr.
24 hr. Clock
2) REPORTING
R/P COMPANY/ R/P CALLBACK
PARTY
NAME:__________________________
AGENCY NAME: ________________________ PHONE NUMBER: (_______)____________________
or ( ______
)____________________
3) R/P ADDRESS:
4) BRIEF
DESCRIPTION OF SITUATION:
_____________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5)
INCIDENTLOCATION:______________________________________________________________________ CITY/COUNTY:_______________________
6) WHAT IS THE MATERIAL (USE EXACT SPELLING)
____________________________________________________________________________________
7) HOW WAS MATERIAL
TOTAL QUANTITY [ ] pounds
[ ] cubic feet
CONTAINED/PACKED:_____________________ QUANTITY:___________________ RELEASED:_________________ [ ]
gallons [ ] _______________
8) AGENCIES NOTIFIED/ON SCENE/RESPONDING:
[ ] Fire
[ ] Police [
] Sheriff [ ] WSP
[ ] WDOE
[ ] USCG [
] USEPA [ ] DOT
[ ]
OTHER______________________________________
9) IS MATERIAL PETROLEUM AND MORE THAN 100 GALLONS? (diesel, hydraulic, gasoline, oil, etc) [YES] [NO] [UNK]
10) IS HUMAN
HEALTH/SAFETY AFFECTED? [YES] [NO]
[UNK]
11) IS GROUND OR SURFACE WATER AFFECTED? [YES]
[NO]
[UNK]
=============================== S A R A
T I T L
1) EMERGENCY
RELEASE REPORT [ ] CONTINUOUS
RELEASE REPORT [ ]
2) DATE(S)
OF RELEASE:_________|_________ TIME(S)_________|_________
DURATION:______________________(minutes/hours)
(Began) (Ended) (Began) (Ended)
3)
SUBSTANCE:_____________________________________________________________ AMOUNT RELEASED:__________________________________
4) IS IT ON LIST (Section 302a)? (As determined by
Reporting Party) [YES] [NO]
MINIMUM QUANTITY FOR REPORTING:________________________
5) ENVIRONMENT:
(air, water, ground, etc)______________________________________ AIR FLOW DIRECTION: FROM______________ TO____________
6) ARE THERE
INDIVIDUALS EXPOSED TO THIS RELEASE ON OR OFF SITE: [YES]
[NO] EXPLAIN:_________________________________________
___________________________________________________________________________________________________________________________________
7) CAUSE OF
RELEASE:_____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
8) POSSIBLE HEALTH
RISKS:__________________________________________________INJURIES?______________________________________________
9) APPROPRIATE
PRECAUTIONS:_____________________________________________________________________________________________________
10) WILL THE
RELEASE AFFECT GROUND/SURFACE WATERS OR ANY
OTHER ENVIRONMENTAL
AREAS?___________________________________
11)
CONTINUOUS
RELEASE PRODUCTS:______________________________________________________________________________________________
*
NOTIFY ON ALL INCIDENTS Notification Date 24 hr. Time Person Notified Remarks
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* 1) LOCAL CONTACT: See TEL 1 |
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Note: For notification of incidents occurring in
Seattle 0800 hrs to 1700 hrs Monday – Friday, call the Seattle Fire Marshall at
ph: (206) 386-1450, fax: (206) 386-1348
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* 2) ECOLOGY: |
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SW (360) 407-6300 NW
(425) 649-7000 CENT (509) 575-2490 EAST
(509) 329-3400
Note:
Notify the appropriate regional Dept of Ecology Office regarding
hazardous material incidents or potential hazardous material incidents
involving
vessels or to report the arrival of vessels into
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3) W.S.P. DISPATCH |
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(All state
right of way incidents. Use WSP mico line for applicable region or tel 22)
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4) EM OPERATIONS MANAGER |
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(If there is
threat to life and/or property. Discuss
notification of EM Director and/or
activation of EOC)
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5) FISH & WILDLIFE: |
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Notify on incidents involving the actual or potential release of petroleum (only) which is reported to be at least 20 gallons into or draining into ,or has the potential of draining into bodies of water.
24 hour pager number: primary (360) 534-8233 alternate (360) 534-3502. If no answer, refer to Tel 22 NO FISH KILLS OR OTHER HAZMATS
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6) HEALTH: |
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For all radiological
incidents – Page RADCON via MyStateUSA.
For
hazardous materials incidents where public health is endangered – primary: (day
– 360-236-4416)(night-360-491-6234)(pager-360-971-0601)
Alternate: see Tel-22
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7) AGRICULTURE: |
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(Any agricultural chemical, pesticide,
fertilizer or possible contamination of foodstuffs. See tel 22)
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8) LABOR AND INDUSTRIES: |
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(Involves
worker/responder exposure to toxic substances.
See L&I Regional Contact Map or tel 22)
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9) UTIL. & TRANS. (Trans. Div.) |
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(If incident
involves a railroad line or public highway and poses a serious threat to life
or property. See tel 22)
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10) FIRE MARSHAL: |
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(If incident
involves the transport, storage or disposal of common or special fireworks
(class B & C explosives) 360-753-0400
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11) NATURAL RESOURCES: |
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(If
incident affects state lands. See DNR
Regional On-Call List or Tel 22)
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12) INDIAN COMMISSION: |
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(If
incident affects Tribal land. See Tribal
Notification List or Tel 22)
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13) B.C. PEP 1-800-663-3456 |
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14) |
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15) |
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16) U.S.CG ( |
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17) U.S.CG ( |
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18) (360) 753-9440 |
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19) FAA: (253) 351-3520 |
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20) FEMA: (206) 487-4600 |
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(For
hazardous materials and radiological incidents involving major threat to life
and property)