120 3rd Avenue
South Charleston, WV 25303
Local emergency planning committee’s (LEPC) requires that Emergency Release follow-up notifications be submitted using this reporting form. Releases of reportable quantities of Extremely Hazardous Substances (EHS) (listed in 40 CFR 355, appendix A) or chemicals that require release reporting under section 103 (a) of the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) must be reported on the form within 14 days following a release. The written follow-up report is required in addition to immediate verbal notification.
SPECIFIC INSTRUCTIONS: Enter the EPA Identification Number, the facility name, phone number, and name of a contact person who can provide detailed information concerning the incident.
Enter the date of the incident, the time that verbal notification was made to the Emergency Management 911 Center, and the National Response Center (NRC) incident number in the space provided.
Provide information about the location where the release occurred. Include the street address, city, state, zip code, county, local emergency planning committee, and if appropriate, provide information about bordering LEPCs or states.
Provide information concerning the specific chemical that was released. Include the chemical/trade name and the Chemical Abstract Service (CAS) number. Check all categories that apply. Provide best available information on quantity, time and duration of the release.
Indicate all actions taken to respond to and contain the release.
Check the categories that apply to the health effects that occurred or could result from the release. Provide an explanation or description of the effects in the space provided. Use the Comment section to provide additional pertinent information.
Include information on the type of medical attention required for exposure to the chemical release. Indicate when and how this information was made available to individuals exposed and to medical personnel, if appropriate for the incident.
List any additional pertinent information.
Print or type the name of the facility representative submitting the report. Include the official signature and the date that the form was prepared.
CALL COUNTY 911 Center: 911
CALL THE NATIONAL REPONSE CENTER: 1 800.424.8802
EMAIL COMPLETED REPORTS TO: Kanawha Putnam Emergency Planning Committee [email protected]