Reporting A Release To The Environment

 “REPORT A RELEASE” FORM
Complete the following to the best of your ability:
Describe the location of the release (e.g., southwest corner of parking lot 6):
 
Date and time release noticed:
  Date: (mm/dd/yyyy)    Time:
Type of release:
 
Release of any substance other than clean water to a campus storm drain
Release of hazardous material to the air
Release of hazardous material to the soil
Release of hazardous material to the sewer
Hazardous material in a trash container (bin or dumpster)
Accidental spill of hazardous material
Release of unknown origin (please describe)
Type of material released (if known):
 
a) Hazardous material
  Material name Volume Units (e.g., gallons, pounds, etc.)
b) "Non-clean water" release to storm drain
  Soil, sand or sediment
  Trash, debris
  Leaves, branches, brush
  Other (please describe)
   
Have any steps been taken to contain the spill?  
  Yes       NO   (If Yes, please describe)
If you witnessed the release, complete the following:
  Description of activity
  Vehicle Description
  Vehicle License Number:  
  Number of Persons Involved:  
  Names of Persons Involved (if known)
  Description of Persons Involved

Your Name (optional)
  First Name:  Last Name:
Your Contact information (optional):
 
Phone
Email
Other
   
 

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