DEP Initial Spill Information Report Form

Please fill in as much of the following as possible, using information provided by the caller/reporting official. Bold fields are of primary importance.

Date of Report _____________________________ and Time ___:___ AM ___ PM ___

Date of Spill/Event _____________________________ and Time ___:___ AM ___ PM ___

Name of caller

Telephone number(s) of caller (include area code)

Company Name (if applicable)

Address

Town __________________________ State _____________________ Zip Code

Name of other informed party ______________________________ Phone Number

Type of product alleged spilled

Estimated amount of spill

Is more spillage possible? ________ (Yes or No) Amount? _______________

Is the situation URGENT? ________ (Yes or No) Is HELP needed? _________ (Yes or No)

Nature of call or complaint

Actions taken so far:

What resources are at risk? (check all that apply)

_____Public Safety

_____Public Water or Well

_____Private Water or Well

_____Atmosphere

_____Land or Ground

_____Open Water

_____Surface Drainage

_____Storm Sewer

_____Sanitary Sewer

_____Vapors in Building

_____None (complaint only)

Location of incident (Town name)

Specific directions to site

responding to oil & hazardou materials spills

DEP Initial Spill Information Report Form