Hazardous Materials Release Reporting Form

Agency

Name

Title

Phone

Incident Date and Time

Incident Information (Directions/address, equipment and materials used)

Organization/Company Name

Address Line 1

Address Line 2

City

State

County

Office Phone

Cell Phone

Email Address

Material/Chemical Name and C.A.S. Number

Estimated Amount Released

LEPC DPS ADOT ARRA Other

Was the National Response Center notified? (1-800-424-8802) Notified Not Notified Unknown

Have you contacted ADEQ at 602-771-2330? Yes No