FormRevised 2021.02.11 Justification

Expiration Date: xx-xx-23

OMB No. 3301-0001

CSB Accidental Release Reporting Form

a1. Owner/Operator: a2. Name of Owner/Operator Contact:

a3. Title of Facility Contact: a4. Mobile Phone Number:

a5. E-mail Address: a6. Office Phone Number:

b1. Name of Person Submitting Report:

b2. Title:

b3. Mobile Phone Number: b4. Office Phone Number:

b5. E-mail:

c1. Facility Name:

c2. Facility Street Address: c3. City: c4. Zip Code:

d1. Time of Accidental Release: d2. Date of Accidental Release:

e. Describe the accidental release:.

f. Indicate if one or more of the following consequences occurred during the accidental release.

Mark all that apply, to the extent known at the time of the incident.

f1. Explosion: Yes No
f2. Fire: Yes No
f3. Death: Yes No
f4. Serious Injury: Yes No
f5. Property Damage: Yes No

g: Name of the materials involved in accidental release using the Chemical Abstract Service (CAS) registry number(s) or other appropriate identifiers. (Add more lines if more than two chemicals.)

g1. CAS Name and Number:

g2. CAS Name and Number:

h. Amount of chemical(s) involved in the accidental release , if known. List chemical name and quantity released. (Use additional page(s) if necessary.)

h1. Quantity Released: _______________________________________________________________

h2. Quantity Released: _______________________________________________________________

i. Number of Fatalities:

j. Number of Serious Injuries:

k. Estimated Property Damage:

l. If known, did the accidental release result in an evacuation order to members of the general public or others? Mark “Yes” or “No.”

Evacuation Order No Yes :

l1. Number of People Evacuated:

l2. Approximate Radius of Evacuation Zone:

l3. Type of individuals subject to evacuation order (i.e., employees, members of the general public, or both). Mark all that apply.

Employees evacuated: Yes No

General public evacuated: Yes No

Signature:
Date

Print Name: First name Last name

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