|Written Reporting of Emergency Releases
The requirements for written reports can be found in the California Code of Regulations - Title 19, Division 2, Chapter 4, Article 2, Section 2705, which states:
If required to submit a written emergency release follow-up notice pursuant to 42 U.S.C. section 11004(c) (1989), or as that section may be subsequently amended, a business shall prepare the written emergency release follow-up notice using the form specified in subsection (c) of this section.
A written emergency release follow-up notice prepared pursuant to subsection (a) shall be sent to the Chemical Emergency Planning and Response Commission (CEPRC) at 3650 Schriever Avenue, Mather, CA 95655. This written report shall be sent as soon as practicable following a release, but no later than 30 days from the date of the release.
The following reporting form (with instructions), the `Emergency Release Follow-up Notice Reporting Form,' shall be used for filing the written emergency release follow-up notice required by subsection (a) of this section.
EMERGENCY RELEASE FOLLOW-UP NOTICE
REPORTING FORM INSTRUCTIONS
(This form may be reproduced, as needed)
Chapter 6.95 of Division 20 of the California Health and Safety Code requires that written emergency release follow-up notices prepared pursuant to 42 U.S.C. § 11004, be submitted using this reporting form. Non-permitted releases of reportable quantities of Extremely Hazardous Substances (listed in 40 CFR 355, appendix A) or of chemicals that require release reporting under section 103(a) of the Comprehensive Environmental Response, Compensation, and Liability Act of 1980 [42 U.S.C. § 9603(a)] must be reported on the form, as soon as practicable, but no later than 30 days, following a release. The written follow-up report is required in addition to the verbal notification.
The form, when filled out, reports follow-up information required by 42 U.S.C § 11004. Ensure that all information requested by the form is provided as completely as possible.
If the incident involves reportable releases of more than one chemical, prepare one report form for each chemical released.
If the incident involves a series of separate releases of chemical(s) at different times, the releases should be reported on separate reporting forms.
Block A: Enter the name of the business and the name and phone number of a contact person who can provide detailed facility information concerning the release.
Block B: Enter the date of the incident and the time that verbal notification was made to OES. The OES control number is provided to the caller by OES at the time verbal notification is made. Enter this control number in the space provided.
Block C: Provide information pertaining to the location where the release occurred. Include the street address, the city or community, the county and the zip code.
Block D: Provide information concerning the specific chemical that was released. Include the chemical or 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.
Block E: Indicate all actions taken to respond to and contain the release as specified in 42 U.S.C. § 11004(c).
Block F: 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 Block H for additional comments/information if necessary to meet requirements specified in 42 U.S.C. § 11004(c).
Block G: Include information on the type of medical attention required for exposure to the chemical released. Indicate when and how this information was made available to individuals exposed and to medical personnel, if appropriate for the incident, as specified in 42 U.S.C. § 11004(c).
Block H: List any additional pertinent information.
Block I: Print or type the name of the facility representative submitting the report. Include the official signature and the date that the form was prepared.
MAIL THE COMPLETED REPORT TO:
Chemical Emergency Planning and Response Commission (CEPRC) /
Local Emergency Planning Committee (LEPC)
Attn: Section 304 Reports
3650 Schriever Avenue,
Mather, CA 95655