Preparer's Name:
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Date Reported to Manager:
(MM/DD/YY)
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Incident Type:
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Date of Incident:(MM/DD/YY)
Time:
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Shift:
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Day of Week:
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Site Location:
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Department/Area:
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Exact Location (be specific):
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On Delta Property:
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Area/Media Affected:
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Materials(s) Involved:
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CAS#
DOT# (UN/NA)
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Is this Hazardous Waste:
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Is this a CERCLA 302(a) - EHS:
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Container:
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Container Size:
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Amount Release:
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Estimate Spill Extent:
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square feet
Duration:
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Cause of Incident:
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Impact Due to Incident:
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Employee Injuries
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Downtime Due to Incident:
Explain:
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Incident Responders Summoned:
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If yes:
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Weather (leave blank if incident was indoors)
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Temp Degrees(F):
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Wind Direction:
Wind Speed:
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Witnesses:
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If yes, Name:
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Building or Equipment Damage: |
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Description of Incident: |
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Containment/Interim Corrective Action Identified/Completed: |
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