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o Name , address , and telephone number of the Store ; <br /> o Date , time , type (e . g . , fire , explosion , spill) , and brief description of the incident ; <br /> o Name and quantity of material (s) involved ; <br /> o The extent of injuries , if any ; <br /> o An assessment of actual or potential hazards to human health or the environment , <br /> where this is applicable ; and <br /> o Estimated quantity and disposition of recovered material that resulted from the <br /> incident . <br /> i <br /> MAY 2096 <br /> REVISION DATE <br /> Page 17 of 20 <br />