CO0040238 - Laserfiche WebLink

Home Browse Search

PARTIV-CONSEQUENCES 30.Result of Incident(check all that apply): 0 Spillage ❑ Fire ❑ Explosion ❑ Material Entered Waterway/Storm Sewer ❑ Vapor(Gas)Dispersion ❑ Environmental Damage ❑ No Release 31.Emergency Response: The following entities responded to the incident: (Check all that apply) ❑ Fire/EMS Report#N/A ❑ Police Report# N/A 0 In-house cleanup ❑ Other Cleanup 32.Damages: Was the total damage cost more than$500? 0 Yes ❑ No If yes,enter the following information: If no,go to question 33. Material Loss: Carrier Damage: Property Damage: Response Cost: Remediation/Cleanup Cost: $ 10 $ 0 $ 0 $ 7,500 $ 0 (See damage definitions in the instructions) 33a.Did the hazardous material cause or contribute to a human fatality? ❑ Yes 0 No If yes,enter the number of fatalities resulting from the hazardous material: Fatalities: Employees N/A Responders N/A General Public WA 33b.Were there human fatalities that did not result from the hazardous material? ❑ Yes S No If yes,how many? N/A 34.Did the hazardous material cause or contribute to personal injury? ❑ Yes EI No If yes,enter the number of injuries resulting from the hazardous material: Hospitalized(Admitted Only): Employees N/A Responders N/A General Public N/A Non-Hospitalized: Employees N/A Responders N/A General Public N/A (e.g.:On site first aid or Emergency Room observation and release) 35.Did the hazardous material cause or contribute to an evacuation? ❑ Yes ❑' No If yes,provide the following information: Total number of general public evacuated N/A Total number of employees evacuated N/A Total Evacuated N/A Duration of the evacuation N/A (hours) 36.Was a major transportation artery or facility closed? ❑ Yes I] No If yes,how many? N/A (hours) 37.Was the material involved in a crash or derailment? ❑ Yes ❑� No If yes,provide the following information: Estimated speed(mph): N/A Weather conditions: N/A Vehicle overturn? ❑ Yes RI No Vehicle left roadway/track? ❑ Yes 0 No PART V - AIR INCIDENT INFORMATION (please refer to § 175.31 to reporta discrepancy for air shipments) 38.Was the shipment on a passenger aircraft? ❑ Yes ❑' No If yes,was it tendered as cargo,or as passenger baggage? ❑ Cargo ❑ Passenger baggage 39.Where did the incident occur(if unknown,check the appropriate box for the location where the incident was discovered)? ❑ Air carrier cargo facility ❑ Sort center ❑ Baggage area ❑ By surface to/from airport ❑ During flight ❑ During loading/unloading of aircraft 40.What phase(s)had the shipment already undergone prior to the incident?(Check all that apply) ❑ Shipment had not been transported ❑ Transported by air(first flight) ❑ Transport by air(subsequent flights) ❑ Initial transport by highway to cargo facility ❑ Transfer at sort center/cargo facility Form DOT F 5800,1 (01-2004) Page 3 Reproduction of this form is permitted