Discharge Reporting Form printable pdf download

Discharge Reporting Form

DEP Form # 62-761.900(1)

Form Title Discharge Reporting Form

PLEASE PRINT OR TYPE

Effective Date

Instructions are on the reverse side. Please complete all applicable blanks

1. Facility ID Number (if registered):_____________________________ 2. Date of form completion:_____________________________________

3. General information

Facility name:___________________________________________________________________________________________________________

Facility Owner or Operator: ________________________________________________________________________________________________

Facility Contact Person___________________________Telephone number: (

)_____________________County: ______________________

Faciility Mailing address: _________________________________________________________________________________________________

Location of discharge (facility street address):__________________________________________________________________________________

Latitude and Longitude of discharge (If known.)________________________________________________________________________________

4. Date of receipt of test results or

5. Estimated number of gallons discharged:_______________

discovery of confirmed discharge: ___________________month/day/year

6. Discharge affected:

[ ] Air

[ ] Soil

[ ] Ground water

[ ] Drinking water well(s)

[ ] Shoreline

[ ] Surface water (water body name)

__________________________

7. Method of discovery (check all that apply)

[ ] Liquid detector (automatic or manual)

[ ] Internal inspection

[ ] Closure/Closure Assessment

[ ] Vapor detector (automatic or manual)

[ ] Inventory control

[ ] Groundwater analytical samples

[ ] Tightness test

[ ] Monitoring wells

[ ] Soil analytical tests or samples

[ ] Pressure test

[ ] Automatic tank gauging

[ ] Visual observation

[ ] Statistical Inventory Reconciliation

[ ] Manual tank gauging

[ ] Other ____________________________________________

8. Type of regulated substance discharged: (check one)

[ ] Unknown

[ ] Used/waste oil

[ ] Jet fuel

[ ] Heating oil

[ ] New/lube oil

[ ] Gasoline

[ ] Aviation gas

[ ] Diesel

[ ] Kerosine

[ ] Mineral acid

[ ] Hazardous substance - includes CERCLA substances from USTs above reportable quantities, pesticides, ammonia, chlorine, and derivatives

(write in name or Chemical Abstract Service (CAS ) number)___________________________________________________________________

[ ] Other_________________________________________________________________________________________________________________

9. Discharge originated from a: (check all that apply)

[ ] Dispensing system

[ ] Pipe

[ ] Barge

[ ] Pipeline

[ ] Vehicle

[ ] Tank

[ ] Fitting

[ ] Tanker ship

[ ] Railroad tankcar

[ ] Airplane

[ ] Unknown

[ ] Valve failure

[ ] Other Vessel

[ ] Tank truck

[ ] Drum

[ ] Other________________________________________________________

10. Cause of the discharge: (check all that apply)

[ ] Loose connection

[ ] Puncture

[ ] Spill

[ ] Collision

[ ] Corrosion

[ ] Fire/explosion

[ ] Overfill

[ ] Human error

[ ] Vehicle Accident

[ ] Installation failure

[ ] Other________________________________

11. Actions taken in response to the discharge:

12. Comments:

13. Agencies notified (as applicable):

[ ] State Warning Point

[ ] National Response Center

[ ] Fire Department.

[ ] County Tanks Program

[ ] DEP (district/person)

1-800-320-0519

1-800-424-8802

_______________

_____________

_________________

14. To the best of my knowledge and belief all information submitted on this form is true, accurate, and complete.

____________________________________________________

_______________________________________________

Printed Name of Owner, Operator or Authorized Representative

Signature of Owner, Operator or Authorized Representative.

Discharge Reporting Form

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