Date & Time of Call:
Taken On:
LEPC 330-675-6602
Other #
Taken By
WHAT IS THE LOCATION OF THE PROBLEM? (Address, City or Township):
WHAT IS THE NATURE OF THE PROBLEM?
WHAT IS YOUR COMPANY NAME?
WHAT IS YOUR NAME AND CALL BACK NUMBER?
Your Email:
HAVE YOU NOTIFIED YOUR LOCAL FIRE DEPARTMENTS?
Yes (Continue)
No
(If emergency, conference call to Fire Department)
FIRE DEPARTMENT'S NAME:
WHAT SUBSTANCE IS LEAKING/SPILLED/RELEASED?
AMOUNT LEAKING/SPILLED/RELEASED
WHAT IS IT LEAKING/BEING RELEASED FROM? (Fixed tank, drum, railcar, etc.).
IS IT:
Gas
Liquid
Solid
Unknown
WHEN DID IT START?
WHEN DID IT END?
WHAT IS THE SUBSTANCE RELEASING INTO? (Air, Ground, Stream, etc.)
CLEAN-UP CONTRACTOR NOTIFIED
Yes
No
WHAT ELSE SHOULD WE KNOW ABOUT THE PROBLEM?
STATE EMERGENCY RESPONSE COMMISSION (OHIO EPA) 1-800-282-9378
NATIONAL RESPONSE CENTER 1-800-424-8802
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