LOUISIANA DEPARTMENT OF ENVIRONMENTAL QUALITY
Secretary Chuck Carr Brown, PhD.

INCIDENT REPORTING - SPILL INCIDENT / RELEASE


Disclaimer


If this is an Emergency,

STOP NOW,

call LSP HAZ MAT hotline 225-925-6595.

A separate notification to LDEQ will not be necessary.

Additionally, this form is ONLY to be used for INITIAL NOTIFICATIONS, it does not fulfill the 7-day written report requirement.

If changes are required for previously submitted notifications, please DO NOT re-submit, call SPOC at 225-219-3640.

The foregoing notwithstanding, Courtesy Notifications/Below Reportable Quantity events may be reported/updated utilizing this form.

If this is a Radiological Complaint/Incident/Allegation

STOP NOW and IMMEDIATELY CALL The LDEQ Radiation Services hotline

at 225-765-0160

(In accordance with Louisiana Regulatory Requirements)


Reference Information

Louisiana State Police HazMat Hotline Report Number (if applicable)
National Response Center Number (if applicable)
AI Number
Permit Number

Reporter Information

* First Name
* Last Name
Title
* Company
* Phone Number
Mailing Address
City
State
Zip
Email (Email must be provided to receive confirmation email)

Responsible Party Information

* Responsible Party Company name
Mailing address (if different from above)
City
State
Zip

Physical Location of Incident

* Address
* City
* State
* Parish of Occurrence

Incident Details

* Date of Discharge
* Noticed Time Began
Noticed Time Ended
* Media Affected
If water, name the nearest water body
If air, note wind direction and weather conditions
* Product / Material release and quantity
* Description of release
How was the spill contained?
How was the spill cleaned?
Directions for reaching the site