AMMONIA RELEASE REPORTING GUIDELINES - Salinas Valley ...

FORM: EPR-2
EMERGENCY RESPONSE CHECKLIST
Location of Leak: Date:
Time of Day leak noticed: Time of day for end of incident:
WEATHER CONDITIONS PRESENT DURING INCIDENT
Temperature: Wind Direction: Speed:
Humidity Fog? Rainy? Cloudy? Clear?
1. Is everyone accounted for?
2. Fire Department name and phone number – HazMat to dispatch from “911”
a) Did you call the Fire Dept. for help? Y / N What time was the call ?
3. Do you need police for traffic control? Y / N What time was the call ?
4. Are there any injured ? Y / N How many ?
5. Do the injured need more than on site first aid ? Y / N
6. How did you transport them? Ambulance or Co-worker :
7. Time of Transportation : _______________________ Destination:
8. OSHA will need to be notified of any employee injury. Time of Call:
9. Name of OSHA individual who took your call:
10. Where any rooms (on-site) evacuated due to ammonia leak? (If Yes, complete below)
Name of _____County Health Department person(s) who authorized re-entry:
Date and Time of authorized re-entry:
WHAT HAPPENED?
(Standard Form used with permission of WPS)
DISCLAIMER: This form is intended to serve as a reference for facility personnel in their development of facility
reporting policy