Laserfiche WebLink
INCIDENT/RELEASE ASSESSMENT FORM <br /> Handlers of hazardous materials are required to report releases.The following is <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? r <br /> 7.Will control,containment,decontamination,and/or clean up ❑ ❑ 4 <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 />