Laserfiche WebLink
Emergency Incident Report <br /> The following report shall be submitted to the California Department of Toxic Substances <br /> Control within 15 days after an emergency involving hazardous waste pursuant to 22 <br /> CCR §66264.5(i). <br /> A. Name of Person Calling: <br /> Title: <br /> Return Telephone Number <br /> B. Name of Facility: <br /> Address of Facility: <br /> Telephone Number: <br /> C. Name of Owner/ Operator: <br /> Address: <br /> Telephone Number: <br /> D. Description of Hazardous Waste Release: <br /> E. Quantity of Material Release: pounds/ gallons <br /> F. Description of Emergency* (e.g.,release, fire, explosion): <br /> G. Date of Incident: 120 <br /> Time of Incident: a.m. /p.m. <br />