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Agency on-site Contact Phone# <br /> Other on-site Contact Phone# <br /> US Ecology, Inc. <br /> Incident Response Form (cont.) <br /> Notifications—Mark all that apply <br /> Agency Notified by Date Time Contact Case/Ref# <br /> ❑ State Environmental <br /> Agency <br /> ❑ EPA <br /> ❑ ❑HP, ❑Police <br /> Sheriff,etc. <br /> ❑ Fire Department <br /> ❑ Other <br /> ❑ NRC <br /> If as a direct result of hazardous materials release,any of the following questions are answered with a <br /> YES,the NRC must be notified immediately at(800)424-8802 per 29 CFR 171.59(A-G); per 40 CRF 110 <br /> (H) <br /> A. Death of individual requiring hospitalization due to hazardous materials El Yes ®No <br /> transportation related injury. <br /> B. Estimated carrier or other property damage exceeding fifty thousand dollars ❑Yes ®No <br /> ($50,000). <br /> C. An evacuation of the general public lasting one or more hours. ❑Yes ®No <br /> D. One or more major transportation arteries or facilities are closed or shut down for one ❑Yes ®No <br /> hour or more. <br /> E. The operational flight pattern or routine of an aircraft is altered. ❑Yes ® No <br /> F. An accident and/or spill involving any one of the materials listed below: E]Yes ® No <br /> Radioactive Material, Etiological Agents or a release of Marine Pollutants exceeding 119 <br /> gallons or 882 lbs. <br /> G. Release greater than the RQ for Hazardous Materials. ❑Yes ® No <br /> H. A navigable waterway or adjoining shoreline has been impacted with oil or water ❑Yes ® No <br /> quality standards could be exceeded or the spill could cause a sheen or the spill could <br /> cause a sludge or emulsion. <br /> Is a written report required by any agency that was notified? <br /> Agency Name <br /> Address <br /> City/State/Zip <br /> Within Days <br /> Agency Name <br /> Address <br /> 5 <br /> Page 8 of 14 <br />