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INCIDENURELEASE ASSESSMENT FORM <br /> Handlers of hazardous materials are required to report releases. The followingis <br /> a tool to be used for assessing if a release is potentially reportable as required by <br /> Chapter 6.95 of the California Health and Safety Code. This assessment tool does <br /> not replace good judgement, Chapter 6.95, or other state or federal release report- <br /> ing requirements. If in doubt, report the release. If an emergency, call 9-1-1. <br /> Questions for Incident Assessment Yes No <br /> 1.Was anyone killed or injured,or did they require medical care ❑ ❑ <br /> or admitted to a hospital for observation? <br /> 2. Did anyone,other than employees in the immediate area of the ❑ ❑ <br /> release,evacuate? <br /> 3. Did the release cause off-site damage to public or private ❑ ❑ <br /> property? <br /> 4. Is the release greater than or equal to a reportable quantity(RQ)? ❑ ❑ <br /> 5. Was there an uncontrolled or unpermitted release to the air? ❑ ❑ <br /> 6. Did an uncontrolled or unpermitted release escape secondary ❑ ❑ <br /> containment, or extend into any sewers, storm water convey- <br /> ance systems,utility vaults and conduits,wetlands,waterways, <br /> public roads,or off-site? <br /> •� 7.Will control,containment,decontamination, and/or clean up ❑ ❑ •' <br /> require the assistance of federal, state, county,or municipal <br /> response elements? <br /> 8.Did the release or threatened release involve an unknown ❑ ❑ <br /> material or contain an unknown hazardous constituent? <br /> 9. Is the incident a threatened release? (a condition creating a ❑ ❑ <br /> substantial probability of harm that requires immediate action <br /> to prevent, reduce, or mitigate damages to persons,property, <br /> or the environment.) <br /> 10. Is there an increased potential for secondary effects including ❑ ❑ <br /> fire,explosion,line rupture,equipment failure, or other <br /> outcomes that may endanger or cause exposure to employees, <br /> the general public, or the environment? <br /> If the answer is YES to any of the above questions- report the release to the <br /> California Governor's Office of Emergency Services Warning Center at(800) <br /> 852-7550 or(916) 845-8911,and to your local UPA. Note: Other state and <br /> federal agencies may require notification depending on the circumstances. <br /> If in doubt, report the release! <br /> 12 <br /> 72 of 8 <br />