Part C: Incident Information Type of Incident: Choose all that apply. Explosion Seismic Fire Stray Gas Loss of Well Gas Release If Gas Release, indicate… Control Fatality Injury Describe… Other Type of Incident: Describe… Estimated Volume Discharge Volume Recovered Exceeded Reportable Inside Outside Inside Outside Federal or State Product(s) Released CAS Number Containment Containment Containment Containment Quantity? Method Was product neutralized? Used? Secondary Containment Verification: Measurements, conditions, capacity Environmental Media Affected REQUIRED Extent/Size/Description Surface area and of contamination Soil Method of detection, PPM, wind direction, if airborn Air Wetland Tiles Drainage Way/Ditch Surface Water Name and length of affected waterway stream, river, lake Groundwater Other OPTIONAL Extent/Size/Description Vegetation crops, timber, etc. Medical advice provided? Worker Exposure Evacuations, level of exposure, health and safety Public Exposure Livestock Wildlife
Part C: Incident Information Type of Incident: Choose all that apply. Explosion Fire Loss of Well Control Seismic Stray Gas Fatality Injury Other Type of Incident: Describe… Gas Release If Gas Release, indicate… Describe… Product(s) Released CAS Number Estimated Volume Discharge Volume Recovered Exceeded Reportable Federal or State Quantity? Inside Containment Outside Containment Inside Containment Outside Containment Was product neutralized? Method Used? Secondary Containment Verification: Measurements, conditions, capacity Environmental Media Affected REQUIRED Extent/Size/Description Soil Surface area and of contamination Air Method of detection, PPM, wind direction, if airborn Wetland Tiles Drainage Way/Ditch Surface Water stream, river, lake Name and length of affected waterway Groundwater Other OPTIONAL Extent/Size/Description Vegetation crops, timber, etc. Worker Exposure Medical advice provided? Public Exposure Evacuations, level of exposure, health and safety Livestock Wildlife
DOGRM_30dayReport.docx