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o Name, address, and telephone number of the Store; <br /> o Date, time, type (e.g., fire, explosion, spill), and brief description of the incident; <br /> o Name and quantity of material(s) involved; <br /> o The extent of injuries, if any; <br /> o An assessment of actual or potential hazards to human health or the environment, <br /> where this is applicable; and <br /> o Estimated quantity and disposition of recovered material that resulted from the <br /> incident. <br /> MAY 2016 <br /> REVISION DATE <br /> Page 17 of 20 <br />