Environmental Incident Report

North Dakota Department of Health
Environmental Health Section
1.701.328.5210

North Dakota Department of Emergency Services
1.701.328.8100
1.800.472.2121 24-Hour Hotline - valid only in North Dakota.

If this is an emergency, or for additional assistance, please call the
Health or Emergency Services Department at the numbers shown above

This form is NOT for RCRA-exempt oilfield related incidents
(for RCRA-exempt oilfield incidents click here)
(if you are not sure which form to use click here)

Fill out information as completely as possible
Error messages appear to the right of the field
Use the Tab key or mouse to move between fields
Pressing the Enter key while in the form will submit the report
Required fields are shown in Red
Map Instructions:
DO NOT USE the ENTER key while in the map
To zoom, use + and - buttons or mouse wheel
To auto fill the required location data, click on the map at the desired location after zooming in to be as accurate as possible
The required location fields on the form always retain the data of the point designated by the red CIRCLE
Searching can be performed based on a 911 street address OR latitude/longitude coordinate
For address searching, type a valid street address and town (DO NOT INCLUDE STATE) into the search box and then click on the magnifying glass icon
For lat/long searching, type the decimal format negative LONGITUDE first, followed by a space and then the decimal format latitude, into the search box and then click on the magnifying glass icon. To convert from Degrees, Minutes, Seconds, use the link below the lat/long date field
If the search is successful, the map will jump to that location and mark it with a green SQUARE
A successful search DOES NOT auto fill. You must click on the square to turn it into a circle which will then auto fill
If you cannot read names or numbers because of lack of contrast, switch to another basemap using the Basemap dropdown

(If above map is not working correctly, click here for the ND Hub Explorer - use layers found under the Government Boundaries and Imagery headings)
LAT/LONG FIELDS ARE NOW REQUIRED - USE MAP TO AUTO FILL ALL THE REQUIRED LOCATION INFORMATION
Location Information:
County  
Township  
Range  
Section  
Quarter
QQSection
QQQSection
Decimal Latitude  
Decimal Longitude  
Collection Method  
Date Lat/Long Recorded  
(Click here to convert Degrees, Minutes, Seconds to Decimal)

Location Description (facility name, 911 address or driving directions from nearest town)
 

Distance to Nearest Residence or Occupied Building Units  


Incident Information:
Date
(mm/dd/yyyy) If unknown, enter date of discovery
Time  
(hhmm 24-hour time, no colon)
Type  


Estimated Duration Units  
Estimated Volume Units  

Substance released or of concern (include trade and/or chemical name if applicable)


Release Contained?  

Agriculture Related?
Is this substance on EPA's Extremely Hazardous Substance list?
To find out if this substance is on the EHS list, Click Here

Describe Cause


Action Taken and Recommended/Planned Future Action
(how spill was contained, soil excavated, emergency approval to burn, evacuation of nearby personnel, etc.)


Where will recovered wastes be disposed?


Impact Information:
Fatalities  
Injuries  
Medium affected

Immediate Risk Evaluation (explosive atmosphere, immediate health hazards, etc.)


Potential Environmental Impacts
(describe impacts to, or likelihood of impacts, to surface water, ground water, soils, etc.)


Responsible Party Information:
Responsible Party  
Address (Line 1)  
Address (Line 2)
City  
State/Province  
Zip
Contact First Name
Contact Last Name
Contact Telephone
Contact Email  
(party at above email address automatically receives email notification)
Property Owner if not the Responsible Party
Has or will the incident be reported to property owner?


Reporting Information:
First Name  
Last Name  
Affiliation
Address (Line 1)  
Address (Line 2)
City  
State/Province  
Zip
Telephone
Fax
Email  
(party at above email address does not automatically receive email notification)
Date Reported
(mm/dd/yyyy)
Time Reported  
(hhmm 24-hour time, no colon)

Other agencies that have or will be notified




Other

To see if this incident is required to be reported to the National Response Center (NRC) Click Here
Has or will the incident be reported to the NRC ?? 1-800-424-8802

Additional E-Mail Recipients to send report to
   
   
   
   
   
Official Use Only:
State Agency Person Who Received Call First Name
Last Name
Telephone
Agency
Department of Emergency Services Incident Number
Send this email to Department of Mineral Resources


Pressing the submit button will send an E-Mail version of this completed Environmental Incident
Report to NDDH Environmental Health Section and ND Dept. of Emergency Services personnel