CITIZEN COMPLAINT / UNAUTHORIZED RELEASE

Put an X in the appropriate box.

RECEIVED BY:

The name of the person who has received the information and is filling out the form.

RECEIVED:

(Date) The date the incident is received in month/date/year format.

EXAMPLE: 11/09/98 (November 9, 1998)

(Time) The time the incident is received in military time (24 hour-clock) .

EXAMPLE: 1305 (1:05 p.m.)

LOG #

( Incident Code) (Year)- (Number)

01- Unauthorized Release

02- Complaint

EXAMPLE: 01-98-001 (First spill received in 1998)

NOTIFIER:

The name of the person who is providing the incident information.

COMPANY NAME:

The current legal operating name of the company subject of the incident.

ADDRESS:

The address used by the facility or site to receive their mail. Be sure to include the zip code.

HOME PHONE:

The notifier's home telephone number if appropriate.

BUSINESS PHONE:

The notifier's business telephone number if appropriate.

PARISH NAME:

Name of the parish where the incident occurred.

INCIDENT INFORMATION

ASSIGNED TO:

The Region and Investigator to which the incident investigation is assigned.

DATE/TIME:

Date and Time of the assignment to the Region/Investigator.

DATE/TIME OCCURRED:

The date and time the incident occurred or was discovered in the month/date/year and military time format.

EXAMPLE: 11/08/98  1400hrs

ALLEGED VIOLATOR:

The name of the person or company believed to be the responsible party of the incident.

NATURE OF INCIDENT:

Include a detailed description of the problem.

IMPACTED:

Place an X in the appropriate boxes. It is possible to have more than one box checked in this section. If Other, fill in the blank.

EXAMPLE: Air ~ Land ~ Surface Water ~ Groundwater ~ Other____________

SOURCE OF RELEASE:

Include a description of the source of the release.

MATERIAL AND AMOUNT RELEASED:

Describe what was released and how much was released from the primary containment vessel.

LOCATION/DIRECTIONS:

Include detailed directions so that the investigator will be able to locate the problem.

INVESTIGATOR COMMENTS:

Additional information may be placed in this blank, but it is primarily intended for the investigator's findings and case disposition.

CONTAINMENT/CLEANUP PLAN:

Information provided by the Notifier or the Investigator on release remediation strategies.