Guide for Preparing HazMat Incidents

Portal detail 1Guide for Preparing HazMat Incidents reporting_instructions_rev.pdf (4.16 MB) Guidance on when a company needs a designated agent and how it must be maintained and communicated. Issued Date: Thursday, January 1, 2004#

Attachment 1, passage 1U.S. Department of Transportation Pipeline and Hazardous Materials Safety Administration Guide for Preparing Hazardous Materials Incidents Reports Revised January 2004 Supersedes Previous Edition#

Attachment 1, passage 2ii • Incident Reporting Guidelines U.S. Department of Transportation Pipeline and Hazardous Materials Safety Administration Hazardous Materials Incident Reporting CONTENTS Overview What Federal Regulation requires me to submit the Report? ............ 1 What is the purpose of the Report? ................................................... 1 Who must complete the Report? ....................................................... 1 What definitions should I know in order to complete the Report? ...... 1 When must I submit a Written Report (DOT Form F 5800.1)? .......... 2 When is a Report not required? ......................................................... 3 When must I make a Telephonic Report? .......................................... 3 What telephone number do I call to make an Immediate Notification of a Hazardous Materials Incident?.............................. 3 How long do I have to submit the Written Report? ............................ 4 Am I required to update the information in the Report? ..................... 4 How and where do I submit my completed Report?........................... 4 How long must I keep a copy of the Report? ..................................... 4 Where must I keep a copy of the Report? ......................................... 4 How can I get a blank copy of the DOT Form F 5800.1? ................... 4 How long does it take to complete the Report? .................................. 4 How can I comment on the length of time needed to complete the Report or on the amount of information required in the Report? ................................................................... 4 Instructions: Completing DOT Form F 5800.1 Part I: Report Type ............................................................................. 5 Part II: General Incident Information .................................................. 5 Part III: Packaging Information .......................................................... 6 Part IV: Consequences ....................................................................... 7 Part V: Air Incident Information .......................................................... 8 Part VI: Description of Events and Packaging Failure ....................... 8 Part VII: Recommendations/Actions Taken to Prevent Future Incidents .............................................................................. 8 Part VIII: Contact Information ............................................................ 8 Failure Codes. ............................................................................... 9 Incident Reporting Requirements (Effective January, 2005) Section 171.15 Immediate Notice of Certain Hazardous Materials Incidents. ......................................................................... 11 Section 171.16 Detailed Hazardous Materials Incident Reports ....... 11 Hazardous Materials Incident Report Form: DOT Form F 5800.1 (01-2004) ....................................................... 13 PHH50-0038-0604#

Attachment 1, passage 3Overview Hazardous Materials Incident Report Department of Transportation Form F 5800.1 What Federal Regulation Requires Me To Submit the Report? The Hazardous Materials Regulations (HMR; 49 CFR Parts 171-180) require certain types of incidents be reported to the Pipeline and Hazardous Materials Safety Administration (PHMSA). Section 171.15 of the HMR requires an immediate telephonic report (within 12 hours) of certain types of hazardous materials incidents. Section 171.16 requires a written report for certain types of hazardous materials incidents within 30 days of the incident, and a follow-up written report within one year of the incident, based on certain circumstances. Each type of report is explained below. (The full text of these sections is at the end of the instructions.) What is the Purpose of the Report? The information you are providing in this report is fundamental to hazardous material transportation risk analysis and risk management by government and industry. It allows us to better understand the causes and consequences of hazardous material transportation incidents. The data is used to identify trends and provide basic program performance measures. It helps to demonstrate the effectiveness of existing regulations and to identify areas where changes should be considered. It also assists all parties, including industry segments and individual companies, to understand the types and frequencies of incidents, what can go wrong, and possible measures that would prevent their recurrence. Your accurate and complete description of incidents can make a significant contribution to continual safety improvement through better regulations, cooperative partnerships, and individual efforts. Who Must Complete the Report? Any person in possession of a hazardous material during transportation, including loading, unloading and storage incidental to transportation, must report to the Department of Transportation (DOT) if certain conditions are met. This means that when the conditions apply for completing the report, the entity having physical control of the shipment is responsible for filling out and filing DOT Form F 5800.1. Generally, the entity having physical control of the shipment during transportation will be the carrier. For incidents that occur when a hazardous material is stored temporarily during transportation, the entity in physical possession of the shipment may be a warehouse or similar storage facility. Loading operations. Incidents that occur while a shipper is loading a hazardous material onto a transport vehicle or into a bulk packaging, such as a cargo tank, portable tank, or rail tank car, before the carrier arrives at the facility to pick up the shipment are not required to be reported because these incidents occur prior to the onset of transportation in commerce. Incidents that occur while the carrier that will be transporting the hazardous material is observing or participating in loading operations must be reported because the carrier is deemed to be in possession of the hazardous material at that point; thus, these incidents occur during transportation. For these incidents, the carrier must complete the report. Unloading operations. Incidents that occur or are discovered while a consignee is unloading a hazardous material from a transport vehicle or bulk packaging after the carrier has delivered the material are not required to be reported because these incidents occur after transportation has ended. Incidents that occur while the carrier that delivered the hazardous material is observing or participating in unloading operations must be reported because the carrier is deemed to be in possession of the hazardous material at that point; thus, these incidents occur during transportation. For these incidents, the carrier must complete the report. What Definitions Should I Know in Order to Complete the Report? In order to accurately complete the report, you should be familiar with the following terms. A complete list of definitions is contained in § 171.8. Bulk packaging—a packaging, other than a vessel or a barge, including a transport vehicle or freight container, in which haz- ardous materials are loaded with no in- OVERVIEW • 1 termediate form of containment and that has: (1) A maximum capacity greater than 450 liters (119 gallons) as a receptacle for a liquid; (2) A maximum net mass greater than 400 kilograms (822 pounds) and a maximum capacity greater than 450 liters (119 gallons) as a receptacle for a solid; or (3) A water capacity greater than 454 kilograms (1,000 pounds) as a receptacle for a gas as defined in § 173.115. Cargo tank—a bulk packaging that is: (1) A tank intended primarily for the carriage of liquids or gases and includes appurtenances, reinforce- ments, fittings, and closures; (2) Permanently attached to or forms a part of a motor vehicle, or is not permanently attached to a motor vehicle but which, by reason of its size, construction, or attachment to a motor vehicle, is loaded or unloaded without being removed from the motor vehicle; and (3) Not fabricated under a specifica- tion for cylinders, intermediate bulk containers, multi-unit tank car tanks, portable tanks, or tank cars. Hazardous material—a substance or ma- terial that has been determined to be ca- pable of posing an unreasonable risk to health, safety, and property when trans- ported in commerce, and that has been so designated. The term includes hazard- ous substances, hazardous wastes, marine pollutants, elevated temperature materials, materials designated as hazardous under the provisions of § 172.101, the Hazard- ous Materials Table (HMT), and materials that meet the defining criteria for hazard classes and divisions in Part 173. Hazardous substance—a material, includ- ing its mixtures and solutions, that— (1) Is listed in Appendix A to § 172.101; (2) Is in a quantity, in one package, which equals or exceeds the re- portable quantity (RQ) listed in Ap- pendix A to § 172.101; and#

Attachment 1, passage 42 • OVERVEIW Table 1 Reportable Quantities. (3) When in a mixture or solution— (i) For radionuclides, conforms to paragraph 7 of Appendix A to § 172.101. (ii) For other than radionclides, is in a concentration by weight which equals or exceeds the concentration corresponding to the RQ of the material, as shown in Table 1. The term hazardous substance does not include petroleum, including crude oil or any fraction thereof which is not otherwise specifically listed or designated as a hazardous substance in Appendix A to § 172.101, and the term does not include natural gas, natural gas liquids, liquefied natural gas, or synthetic gas useable for fuel (or mixtures of natural gas and such synthetic gas). Hazardous waste—any material that is subject to the Hazardous Waste Manifest Requirements of the U.S. Environmental Protection Agency specified in 40 CFR Part 262. Loading incidental to movement —load- ing by carrier personnel or in the pres- ence of carrier personnel of packaged or containerized hazardous material onto a transport vehicle, aircraft, or vessel for the purpose of transporting it, including the loading, blocking, and bracing of a haz- ardous materials package in a freight con- tainer or transport vehicle, and segregat- ing a hazardous material in a freight con- tainer or transport vehicle from incompat- ible cargo. For a bulk packaging, load- ing incidental to movement means filling the packaging with a hazardous material for the purpose of transporting it. Load- ing incidental to movement includes transloading. Marine pollutant—a material that is listed in Appendix B to § 172.101 (also see § 171.4) and, when in a solution or mix- ture of one or more marine pollutants, is packaged in a concentration that equals or exceeds: (1) Ten percent by weight of the solu- tion or mixture for materials listed in Appendix B; or (2) One percent by weight of the so- lution or mixture for materials that are identified as severe marine pollutants in Appendix B. Movement—the physical transfer of a hazardous material from one geographic location to another by rail car, aircraft, motor vehicle, or vessel. Storage incidental to movement— storage of a transport vehicle, freight container, or package containing a hazardous material by any person between the time that a carrier takes physical possession of the hazardous material for the purpose of transporting it until the package containing the hazardous material is physically delivered to its destination. Transloading—the transfer of a hazardous material from one bulk packaging to another bulk packaging, from a bulk packaging to a non-bulk packaging, or from a non-bulk packaging to a bulk packaging for the purpose of continuing the movement of the hazardous material in commerce. Transportation—the movement of property and loading, unloading, or storage incidental to that movement. Undeclared hazardous material—a hazardous material that is: (1) Subject to any of the hazard com- munication requirements in sub- parts C (Shipping Papers), D (Marking), E (Labeling), and F (Placarding) of Part 172 of this subchapter, or an alternative marking requirement in Part 173 of this subchapter (such as §§ 173.4(a)(10) and 173.6(c)); and (2) Offered for transportation in com- merce without any visible indica- tion to the person accepting the hazardous material for transpor- tation that a hazardous material is present, on either an accom- panying shipping document, or the outside of a transport vehicle, freight container, or package. Unintentional release—the escape of a hazardous material from a package on an occasion not anticipated or planned. This includes releases resulting from collision, package failures, human error, criminal activity, negligence, improper packing, or unusual conditions such as the operation of pressure relief devices as a result of over- pressurization, overfill, or fire exposure. It does not include releases, such as venting of packages, where allowed, and the operational discharge of contents from packages. Unloading incidental to movement— removing a packaged or containerized hazardous material from a transport vehicle, aircraft, or vessel, or, for a bulk packaging, emptying a hazardous material from the bulk packaging after the hazardous material has been delivered to the consignee when performed by carrier personnel or in the presence of carrier personnel. Additionally, for purposes of reporting on this form, the following definitions apply: Lading retention system—a lading retention system consists of those items or equipment that provide containment of hazardous materials at some point during transporta- tion, including loading and unloading. The cargo tank shell, associated piping, and valves are an example of a lading reten- tion system. Dents or damage to a tank requiring repair to an accident protection system guarding the tank are examples of incidents that must be reported. Paint chips and scratches to either the tank or the acci- dent protection system are examples of in- cidents that do not require reporting. Major transportation artery—a highway, main road or secondary road but not a side street or dirt road. In the case of rail, any rail line except a rail spur. When Must I Submit a Written Report (DOT Form F 5800.1)? Under § 171.16, you must submit a written report within 30 days after any of the following: • An incident that was reported by telephonic notice under § 171.15; • An unintentional release (see definitions) of a hazardous material during transportation including loading, unloading and temporary storage related to transportation; • A hazardous waste is released;#

Attachment 1, passage 5OVERVIEW • 3 Table 2 Examples to Clarify When to Report Structural Damage to a Specification Cargo Tank. • An undeclared shipment with no release is discovered; or • A specification cargo tank 1,000 gallons or greater containing any hazardous materials that— (1) Received structural damage to the lading retention system or damage that requires repair to a system intended to protect the lading retention system, and (2) Did not have a release. To clarify the requirement for a report based on structural damage to a specification cargo tank, Table 2 illustrates some examples. When Is a Report Not Required? You are not required to report a release of a hazardous material if ALL of the following apply: • The shipment is not being offered for transportation or being transported by air; • None of the criteria in § 171.15(a) applies; • The material is not a hazardous waste; • The material is properly classed as an ORM-D, or a Packing Group III material in Class or Division 3, 4, 5, 6.1, 8, or 9; • Each package has a capacity of less than 20 liters (5.2 gallons) for liquids or less than 30 kg (66 pounds) for solids; • The total aggregate release is less than 20 liters (5.2 gallons) for liquids or less than 30 kg (66 pounds) for solids; • The material does not meet the definition of an undeclared hazardous material in § 171.8; and • The shipment is an undeclared material discovered in an air passenger’s checked or carry-on baggage during the airport screening process. Also, you are not required to report releases of minimal amounts of material (i.e., a pint or less) released from the manual operation of seals of pumps, compressors, or valves, during the connecting or disconnecting of loading and unloading lines, or, for materials for which venting is authorized, from vents, provided these releases do not result in property damage or trigger any of the telephonic notifications requirements found in § 171.15. When Must I Make a Telephonic Report? Under § 171.15, you must provide telephone notice within 12 hours after the incident occurs when one of the following conditions occurs during the course of transportation and is a direct result of the hazardous material: • A person is killed; • A person receives an injury requiring admittance to a hospital; • The general public is evacuated for one hour or more; • One or more major transportation arteries or facilities are closed for one hour or more; • The operational flight plan or routine of an aircraft is altered; • Fire, breakage, spillage or suspected radioactive contamination occurs involving a radioactive material; • Fire, breakage, spillage or suspected contamination occurs involving an infectious substance other than a diagnostic specimen or regulated medical waste; • There is a release of a marine pollutant in a quantity exceeding 450 liters (119) gallons for liquids or 400 kilograms (882 pounds) for solids; or • A situation exists of such a nature that in the judgment of the person in possession of the hazardous material, it should be reported to DOT’s National Response Center (NRC) even though it does not meet the above criteria. You may decide that the situation should be reported even though it does not meet any of the above criteria. Make sure that you request the NRC report number when you make your telephonic report. What Telephone Number Do I Call to Make an Immediate Notification of a Hazardous Materials Incident? You must call 800-424-8802 (toll-free) or 202-267-2675 (toll call) to make a telephonic incident report. This is the number to the NRC.#

Attachment 1, passage 64 • INSTRUCTIONS This call must be made within 12 hours of the events that trigger this requirement. If the incident involves an infectious substance, you may notify the Director, Center for Disease Control and Prevention (CDC), U.S. Public Health Service, Atlanta, Georgia, toll free at 800-232- 0124. If a discrepancy of a shipment intended for air is discovered following its acceptance aboard aircraft, notify the nearest Federal Aviation Administration Civil Aviation Security Office as soon as practical. • You can submit the report on-line at http://hazmat.dot.gov. How Long Must I Keep a Copy of the Report? You must keep a copy of each report or an electronic image of the report for two years after the date you submit it to PHMSA (§ 171.16(b)(3)). Where Must I Keep a Copy of the Report? The report must be accessible through your company’s principal place(s) of business. How Long Do I Have to Submit You must be able to make the report avail- the Written Report? able upon request to authorized represen- You must submit your written report within tatives or a special agent of the Depart- 30 days of discovery of the incident, 30 days of discovery of the incident, 30 days of discovery of the incident, 30 days of discovery of the incident, 30 days of discovery of the incident, ment within 24 hours of such a request § 171.16(a). (§ 171.16(b)(3)). Am I Required to Update the Information in the Report? Yes. You must use DOT Form F 5800.1 and check the “A supplemental (follow-up) report” box on question #2 to provide additional information after the initial re- port. You are required to provide updates for up to one year after the initial filing if more information is gained or new devel- opments arise concerning the following, for example: • A death results from injuries caused by a hazardous material; • The person responsible for pre- paring the original report learns that there is a misidentification of hazardous material or pack- age information; • Damage or loss or related costs that were not known at the time the report was filed become known; or • Revised estimates of damages, losses, and related costs result in a change of $25,000 or more, or 10% of the original cost esti- mates, whichever is greater, even if the original estimate was un- der $500. How and Where Do I Submit My Completed Report? • You can mail paper copies of the report to the Information Systems Manager, U.S. Department of Transportation, Pipeline and Hazardous Materials Safety Administration, Office of Hazardous Materials Safety, PHH-63, Washington, DC 20590-0001; or How Can I Get a Blank Copy of the DOT Form F 5800.1? There are a variety of sources for obtain- ing the DOT Form F 5800.1. Please note that you are allowed to make unlimited photocopies of the form and distribute them. • You may obtain limited copies of the form from the Information Systems Manager at the above address. • You may download a copy of the form from our website at http://hazmat.dot.gov/spills.htm • Our Fax on Demand service has copies of the instructions and the form. Call 800-467-4922 and choose the Fax on Demand op- tion #2. How Long Does It Take To Complete the Report? PHMSA anticipates that it will take you approximately 1.6 hours to complete this report. This estimate includes the time it will take you to review the instructions, search your existing data sources for in- formation, gather the required data, and complete and review the report. How Can I Comment on the Length of Time Needed to Complete the Report or on the Amount of Information Required in the Report? You can send your comments on the report, and any suggestions you have for reducing the amount of time needed to complete the report, to the following address: (1) Information Systems Manager, U.S. Department of Transportation, Pipeline and Hazardous Materials Safety Administration, Office of Hazardous Materials Safety, PHH-63, Washington, DC 20590-0001. Please verify that your information is accurate. Although the required information is generally available at the time of the incident, you may need to do some additional investigation in order to obtain all of the facts pertaining to deaths, injuries or damage amounts. If you submit complete and accurate information at the time you file the report, it will decrease the chance of your having to supply missing information to DOT at a later date. PHMSA may follow up on incomplete forms.#

Attachment 1, passage 7Instructions Completing DOT Form F 5800.1 Please print. Fill in all applicable blanks accurately to the best of your ability. Part I: Report Type (1) This is to report: Check the box that describes why you are filling out this form. This will normally be “A) A hazardous material incident.” If you are reporting an undeclared shipment with no release, check the corresponding box, “B).” If you are reporting an incident involving a cargo tank motor vehicle containing a hazardous material that received structural damage to the lading retention system that may affect its ability to retain lading but does not release a hazardous material, check that appropriate box, “C).” (2) Indicate what type of report this is: If this is an initial report, check the “initial report” box. If this is a follow-up to a previous report, check the “A supplemental (follow-up) report” box. If you are using additional pages, check the “Additional Pages” box. Part II: General Incident Information (3), (4) Date & Time of Incident: Enter the date and time the incident occurred. If you do not know the actual date and time, give the date and time you discovered the incident. Use 24-hour time for the incident time (e.g., “2400” for midnight, “1200” for noon, “0747” for 7:47 a.m., “2115” for 9:15 p.m.). (5) Enter National Response Center Report Number: If this incident was reported to the NRC, fill in the report number NRC assigned to the incident. (6) If you submitted a report to another Federal DOT agency, enter the agency and report number: If you were required to fill out a report for another federal agency such as the Federal Railroad Administration (FRA) or the Federal Motor Carrier Safety Administration (FMCSA) for this incident, please include the agency and report number. This will facilitate our combination of information. (7) Location of Incident: Enter the geo- graphic location of the incident (city, county, state, and zip code). If you do not know the actual loca- tion where the incident occurred, give the location where it was dis- covered. If the incident occurred at an airport or rail yard, include the name of the facility. If the inci- dent occurred on a body of water, include the name and/or river mile. If you do not know the street ad- dress, or if the incident occurred on a highway, include a descrip- tion such as “On I-70, mile marker 240.” (8) Mode of Transportation: Enter the code that corresponds to the mode of transportation in which the incident occurred or was discov- ered. If the incident occurred or was discovered in an in-transit stor- age area (e.g., a terminal or ware- house), check the box that corre- sponds to the mode by which the package was last transported. (9) Transportation Phase: Enter the code that describes where the in- cident occurred in the transporta- tion system. In transit means the incident occurred or was first discovered while the package was in the process of being transported. In-transit storage is storage inci- dental to transportation, such as at a terminal waiting for the next leg of transportation. (10) Carrier/Reporter: Provide the name, street address, Federal DOT number (if applicable), and hazmat registration number of the carrier or the entity who is reporting the incident (if other than a carrier). The entity in physical possession of the material when the incident oc- curred or was discovered must re- port the incident. (11) Shipper/Offeror: Enter the informa- tion about the person or entity that originally offered for transportation the material or package involved in the incident. (12) Origin: Enter the origin of the ship- ment if the address is different than the shipper/offeror information entered in item #11. INSTRUCTIONS • 5 (13) Destination: Enter the final destina- tion of the shipment involved in the incident. (14) through (19): Hazardous Material Description: Enter the proper shipping name, technical or trade name, hazard class or division, ID number, packing group, and amount of material released. All of this information, except the amount of material released, can be found on the shipping papers that accompany the shipment, § 172.202. When indicating the amount of material released, include units of measurements (e.g.: 115 gallons, 69 tons). (20) Was the material shipped as a hazardous waste? Check the “Yes” box if the material meets the defi- nition of a hazardous waste in § 171.8 (requires an EPA Uniform Hazardous Waste Manifest). In- clude the EPA Manifest number. (21) (22) (23) Is this a Toxic by Inhalation (TIH) material? If the material involved in the incident meets the definition of a Toxic by inhalation material in § 173.132, check the "Yes" box and enter the Hazard Zone in the space provided. Was the material shipped under an Exemption, Approval, or Compe- tent Authority Certificate? If the shipment was shipped under an ex- emption, an approval, or a Com- petent Authority Certificate, check the “Yes” box and provide the ap- propriate assigned number. Was this an undeclared hazardous materials shipment? If this material was not indicated in any way to be a hazardous material even though it was required to be de- scribed as such on a shipping pa- per, or if the material would nor- mally be excepted from the ship- ping paper requirements (such as a small quantity material) and does not have the required markings, it is considered an undeclared haz- ardous material shipment. Check the appropriate box.#

Attachment 1, passage 86 • INSTRUCTIONS Table 3 Non-bulk and IBC Packaging Identification Codes. Part III: Packaging Information (24) (25) Packaging Type: Check the box that corresponds to the type of packag- ing involved in the incident. If more than one packaging type was in- volved in an incident, reproduce Part III of the form and fill out this section for each of the packaging types. For example, if three differ- ent packaging types were involved in an incident, fill out a separate Part III for each packaging type. If the type of packaging is not repre- sented, check the “Other” box and enter a brief description such as “non-specification bulk bin.” Enter the appropriate failure codes (found at the end of the instructions): Enter the codes that describe what failed on the packaging, how the packaging failed, and the cause(s) of the failure. Be sure to enter the codes from the list that corresponds to the particular packaging types checked above (#24). Enter the most important failure point in line 1. If there is a second failure point, enter in line 2. If there are more than two failure points, provide ad- ditional information in this format in Part VI. The following explains the content of each line: What Failed: You can enter up to 2 “What Failed” codes to describe the part of the pack- aging that fails and was the im- mediate cause of the release. Often, on a simple packaging, only one code will be required. On more complex packaging, additional entries will help identify where that failure oc- curred. The first entry should designate the specific point of failure, followed by entries that help identify where that failure occurred. For instance, a dete- riorated gasket on a pipe flange on the liquid line would have failure code 121 for gas- ket entered first and failure code 118 for flange entered second. How Failed: Enter the “Fail- ure” code that describes how the corresponding part of the packaging failed. The primary way the packaging failed should be entered first. Cause(s) of Failure: Enter the “Cause of Failure” code that describes what caused the cor- responding part of the packag- ing to fail in the way it did. The most probable or fundamental cause of failure should be en- tered first. If none of the codes on the list fit exactly, use the closest match and provide additional detail in Part VI. Also, if you believe a better set of codes would be more descriptive of what failed, how it failed, and the causes of failure, suggest them in Part VII. (26a) Provide the complete packaging identification markings, if avail- able: Every specification packag- ing, UN or DOT, has a packaging identification printed or stamped on it or on a plate attached to the packaging. Examples are pro- vided on the form. (26b) For Non-bulk, IBC, or non-specifi- cation packaging: Only fill out 26b if the marking is incomplete, de- stroyed, or unknown. Fill in the Outer and Inner packaging type and Material of Construction infor- mation, as appropriate. If the pack- aging is non-bulk or Intermediate Bulk Container (IBC), use the codes in Table 3 to enter the number or letter that applies for either non-bulk or IBC packaging. For non-bulk, IBC or non-specification packaging provide a description of the pack- aging in the space(s) provided. (27) Describe the package capacity and the quantity: Enter the total capacity of the inner and outer package. Also enter the actual amount of hazardous material that was shipped in the package, the number of packages in the shipment, and the number of packages that failed. Please include the units of measurement (liter, gallons, pounds, cubic feet, etc.) (28) Provide package construction and test information, as appropriate: In the case of Non-bulk packagings#

Attachment 1, passage 9or IBCs enter the name of the packaging manufacturer or the symbol of the manufacturer only if complete identification markings were not provided in #26b. Enter the date of manufacture and the serial number, if applicable. Enter the last test date if the packaging requires periodic testing. Also include the design pressure, shell thickness, head thickness, and service pressure if the failed packagings are of the type indicated in parenthesis after each question. If the packaging contained a valve, or other device that failed and resulted in a hazardous material release, enter the valve or device type, manufacturer (if present and legible), and model number (if present and legible). (29) If the package is for Radioactive Materials, complete the following: Complete this question only if a radioactive material was involved. Indicate the packaging category, the packaging certification, certification number, and which nuclides were present, the transportation index (TI), activity of the nuclides, and the criticality safety index. Part IV: Consequences (30) Result of Incident: Check all boxes that describe what occurred during the incident or as a result of the incident. For example, in a situation where a truckload of 55 gallon drums of corrosive liquids overturns resulting in a release that contaminates a nearby wetlands and stream the boxes “Spillage,” “Material Entered Waterway/Storm Sewer,” and “Environmental Damage” may apply. (31) Emergency Response: Check all boxes that correspond with any emergency response and cleanup crews that participated in resolving the incident. If a fire crew, EMS, or police unit responded to the incident, include the report number. (32) Damages: You are required to provide information on estimated damages if your damages exceed $500.00. This figure includes the cost of the material lost, property damage, vehicle damage, response costs, and clean-up costs. If you do not know these amounts at the time you complete the report, or the actual costs are revised by more than $25,000, you must submit a follow-up report after you determine the amounts. The following definitions explain each of the costs: Material Loss: Enter the value of material released and unrecoverable. Base this entry on the amount of material released multiplied by the unit value (e.g., price per gallon or price per pound) as listed on the shipper’s invoice. If the invoice is not available, estimate the cost per unit using the shipper’s basis. Carrier Damage: Enter the total value of damage incurred by the carrier. Major components include costs to repair the damaged vehicle and costs resulting from damage to cargo. If the vehicle is declared “totaled,” enter the insured value of the vehicle. This entry should not include damage to other property or to vehicles owned by other persons. Property Damage: Enter the total value of costs resulting from damage to the property of others involved in the incident. These include: repair and replacement costs of other vehicles; repair and replacement costs to buildings and other fixed facilities; and restoration of open land beyond decontamination and cleanup. Response Cost: Enter the total value of response costs. Response costs are those costs incurred immediately after the incident, and include local emergency response from police and fire departments and emergency response teams, as well as costs incurred by the responsible party. Response costs also include costs to contain the hazardous material released. INSTRUCTIONS • 7 Remediation/Cleanup Cost: Enter the total value of the cost to cleanup and remediate the site. Cleanup costs are those costs incurred to collect, transport, and ultimately dispose of all material collected during the response phase. Remediation costs are those costs incurred to restore the incident scene to its pre- incident state, and could include excavation, disposal and replacement of contaminated soil, pumping, treatment and re-injection of contaminated groundwater, or absorption and disposal of hazardous material released into surface water. (33a) Did the hazardous material cause or contribute to a human fatality? If a person was fatally injured by contact with the hazardous material or its vapors or by a fire or explosion that resulted from the hazardous material, check the “Yes” box and enter the number of fatalities that resulted directly from the hazardous material. (33b) Were there human fatalities that did not result from the hazardous material? If the fatalities were not caused directly by the hazardous material, check the “Yes” box and enter the number of fatalities. An example: if a passenger car collided with a cargo tank carrying gasoline and the automobile driver was killed due to the collision, then the fatality was not caused by the hazardous material released. If, however, the accident resulted in the release of gasoline from the cargo tank and a resulting fire killed the automobile driver, then the fatality was caused by the hazardous material. (34) Did the hazardous material cause or contribute to a personal injury? If a person was injured by contact with the hazardous material or its vapors or by a fire or explosion that resulted from the hazardous material, check the “Yes” box and enter the number of persons injured by the hazardous material.#

Attachment 1, passage 108 • INSTRUCTIONS (35) (36) (37) Hospitalized means admitted to a medical facility, not treated and released from a facility, such as a hospital emergency room, where the person was never admitted to the hospital proper. Non- hospitalized individuals are those who may have received attention from medical personnel on-site or at a facility (including hospital emergency room), but were not admitted to a medical facility. Indicate the number of injured employees,emergency responders (firefighters, police, medics, etc.) and members of the general public. Did the hazardous material cause or contribute to an evacuation? If the incident required the evacuation or removal of persons from a specific area because of possible or actual contact with the hazardous materials involved in the incident, check the “Yes” box. Separately specify the numbers of individuals from the general public evacuated and number of employees of the facility or workers in the area that were evacuated. Also provide the total number of individuals evacuated. Indicate the duration of the evacuation (in hours). Was a transportation artery or facility closed? If a road or transportation facility was closed due to the incident, check the “Yes” box and indicate the duration (in hours) here. Was the material involved in a crash or derailment? Check the “Yes” box if a hazardous material was involved in a crash or derailment. Provide the estimated speed and weather conditions at the time of the crash, such as rain, blowing snow, sleet, iced roadway, sun glare, fog, dry pavement, high winds, etc. Indicate if the vehicle overturned or left the roadway or track. Part V: Air Incident Information This section is for incidents with packagings transported or intended for transportation by aircraft. If your packaging was not transported or intended to be transported by air, skip this section. (38) (39) (40) Was the shipment on a passenger aircraft? Indicate whether the shipment in question was on a commercial passenger aircraft. If so, indicate if the material was tendered (accepted for shipment) as cargo, or was located in a passenger’s baggage, either in the cabin or baggage compartment. Where did the incident occur or where was the incident discovered? Indicate where in the course of transportation the incident occurred or was discovered. What phase(s) had the shipment already undergone prior to the incident? Check all boxes that describe the transportation phases the shipment went through before the incident occurred or was discovered. Part VI: Description of Events and Packaging Failure Please describe the events involved in the incident to provide us with a better understanding of the incident. Include information that has not been collected elsewhere on this form, and include special scenarios, outstanding circumstances, or other information that provides a complete picture of the incident. Describe the sequence of events that led to the incident, the package failure (if any) and actions taken at the time of discovery. Submit photographs and diagrams when necessary for clarification. You may continue on additional sheets if necessary. Part VII: Recommendations/ Actions Taken to Prevent Future Incidents Recommendations may be preliminary in nature, may suggest actions by other parties, and may be subject to further investigation, refinement, acceptance, or rejection. Often, it may be beyond the ability of the preparer to offer recommendations, but where such recommendations can be made they have the potential of resulting in important improvements with safety benefits. For instance, such information can help companies identify common problems and alert the DOT to the need for additional measures such as outreach or broad training needs. This information can also help support regulatory changes. Part VIII: Contact Information Provide the name, title, telephone number, fax number, business name and address, hazmat registration number and email address of the contact person at your company who can answer questions about the information provided on this form. Make sure to check the box that describes the function of your firm: carrier, shipper, facility owner/operator, or other. If “Other” is checked, describe the function.#

Attachment 1, passage 11Failure Codes for All Packaging Types—Complete List Code What Failed 101 Air Inlet 102 Auxiliary Valve 103 Basic Material 104 Body 105 Bolts or Nuts 106 Bottom Outlet Valve 107 Check Valve 108 Chime 109 Closure (e.g., Cap, Top, or Plug) 110 Cover 111 Cylinder Neck or Shoulder 112 Cylinder Sidewall - Near Base 113 Cylinder Sidewall - Other 114 Cylinder Valve 115 Discharge Valve or Coupling 116 Excess Flow Valve 117 Fill Hole 118 Flange 119 Frangible Disc 120 Fusible Pressure Relief Device or Element 121 Gasket 122 Gauging Device 123 Heater Coil 124 High Level Sensor 125 Hose 126 Hose Adaptor or Coupling 127 Inlet (Loading) Valve 128 Inner Packaging 129 Inner Receptacle 130 Lifting Feature 131 Lifting Lug 132 Liner 133 Liquid Line 134 Liquid Valve 135 Loading or Unloading Lines 136 Locking Bar 137 Manway or Dome Cover 138 Mounting Studs 139 O-Ring or Seals 140 Outer Frame 141 Piping or Fittings 142 Piping Shear Section 143 Pressure Relief Valve or Device - Non-Reclosing 144 Pressure Relief Valve or Device -Reclosing 145 Remote Control Device 146 Sample Line 147 Stub Sill (Tank Car) 148 Sump 149 Tank Head 150 Tank Shell 151 Thermometer Well 152 Threaded Connection 153 Vacuum Relief Valve 154 Valve Body 155 Valve Seat 156 Valve Spring 157 Valve Stem 158 Vapor Valve 159 Vent 160 Washout 161 Weld or Seam Code How Failed 301 Abraded 302 Bent 303 Burst or Ruptured 304 Cracked 305 Crushed 306 Failed to Operate 307 Gouged or Cut 308 Leaked 309 Punctured 310 Ripped or Torn 311 Structural 312 Torn Off or Damaged 313 Vented Code Cause(s) of Failure 501 Abrasion 502 Broken Component or Device 503 Commodity Self-ignition 504 Commodity Polymerization 505 Conveyer or Material Handling Equipment Mishap 506 Corrosion - Exterior 507 Corrosion - Interior 508 Defective Component or Device 509 Derailment 510 Deterioration or Aging 511 Dropped 512 Fire, Temperature, or Heat 513 Forklift Accident 514 Freezing 515 Human Error 516 Impact with Sharp or Protruding Object (e.g., nails) 517 Improper Preparation for Transportation 518 Inadequate Accident Damage Protection 519 Inadequate Blocking and Bracing 520 Inadequate Maintenance 521 Inadequate Preparation for Transportation 522 Inadequate Procedures 523 Inadequate Training 524 Incompatible Product 525 Incorrectly Sized Component or Device 526 Loose Closure, Component, or Device 527 Misaligned Material, Component, or Device 528 Missing Component or Device 529 Overfilled 530 Over-pressurized 531 Rollover Accident 532 Stub Sill Separation from Tank (Tank Cars) 533 Threads Worn or Cross Threaded 534 Too Much Weight on Package 535 Valve Open 536 Vandalism 537 Vehicular Crash or Accident Damage 538 Water Damage INSTRUCTIONS • 9 Failure Codes by Packaging Type General Non-bulk and IBCs Code What Failed 103 Basic Material 104 Body 105 Bolts or Nuts 108 Chime 109 Closure (e.g., Cap, Top, or Plug) 110 Cover 119 Frangible Disc 120 Fusible Pressure Relief Device or Element 121 Gasket 125 Hose 128 Inner Packaging 129 Inner Receptacle 130 Lifting Feature 132 Liner 140 Outer Frame 143 Pressure Relief Valve or Device - Non-Reclosing 144 Pressure Relief Valve or Device - Reclosing 161 Weld or Seam Code How Failed 301 Abraded 302 Bent 303 Burst or Ruptured 304 Cracked 305 Crushed 306 Failed to Operate 307 Gouged or Cut 308 Leaked 309 Punctured 310 Ripped or Torn 311 Structural 312 Torn Off or Damaged 313 Vented Code Cause(s) of Failure 501 Abrasion 503 Commodity Self-ignition 504 Commodity Polymerization 505 Conveyer or Material Handling Equipment Mishap 506 Corrosion - Exterior 507 Corrosion - Interior 508 Defective Component or Device 510 Deterioration or Aging 511 Dropped 513 Forklift Accident 514 Freezing 515 Human Error 516 Impact with Sharp or Protruding Object (e.g., nails) 517 Improper Preparation for Transportation 521 Inadequate Preparation for Transportation 522 Inadequate Procedures 523 Inadequate Training 529 Overfilled 530 Overpressurized 534 Too Much Weight on Package 535 Valve Open 536 Vandalism 537 Vehicular Crash or Accident Damage 538 Water Damage#

Attachment 1, passage 1210 • INSTRUCTIONS Failure Codes by Packaging Type (continued) Cylinders Code What Failed 111 Cylinder Neck or Shoulder 112 Cylinder Sidewall - Near Base 113 Cylinder Sidewall - Other 114 Cylinder Valve 119 Frangible Disc 120 Fusible Pressure Relief Device or Element 122 Gauging Device 132 Liner 143 Pressure Relief Valve or Device - Non- Reclosing 144 Pressure Relief Valve or Device - Reclosing 161 Weld or Seam Code How Failed 301 Abraded 303 Burst or Ruptured 304 Cracked 306 Failed to Operate 307 Gouged or Cut 308 Leaked 309 Punctured 313 Vented Code Cause(s) of Failure 501 Abrasion 502 Broken Component or Device 503 Commodity Self-ignition 504 Commodity Polymerization 505 Conveyer or Material Handling Equipment Mishap 506 Corrosion - Exterior 507 Corrosion - Interior 508 Defective Component or Device 510 Deterioration or Aging 512 Fire, Temperature, or Heat 513 Forklift Accident 514 Freezing 515 Human Error 516 Impact with Sharp or Protruding Object (e.g., nails) 517 Improper Preparation for Transportation 519 Inadequate Blocking and Bracing 520 Inadequate Maintenance 521 Inadequate Preparation for Transportation 522 Inadequate Procedures 523 Inadequate Training 524 Incompatible Product 525 Incorrectly Sized Component or Device 526 Loose Closure, Component, or Device 527 Misaligned Material, Component, or Device 528 Missing Component or Device 529 Overfilled 530 Over-pressurized 535 Valve Open 536 Vandalism 537 Vehicular Crash or Accident Damage Portable Tanks Code What Failed 105 Bolts or Nuts 106 Bottom Outlet Valve 107 Check Valve 108 Chime 109 Closure (e.g., Cap, Top, or Plug) 110 Cover 119 Frangible Disc 120 Fusible Pressure Relief Device or Element 121 Gasket 122 Gauging Device 125 Hose 127 Inlet (Loading) Valve 131 Lifting Lug 132 Liner 135 Loading or Unloading Lines 137 Manway or Dome Cover 140 Outer Frame 141 Piping or Fittings 143 Pressure Relief Valve or Device - Non-Reclosing 144 Pressure Relief Valve or Device - Reclosing 152 Threaded Connection 153 Vacuum Relief Valve 161 Weld or Seam Code How Failed 301 Abraded 302 Bent 303 Burst or Ruptured 304 Cracked 305 Crushed 306 Failed to Operate 307 Gouged or Cut 308 Leaked 309 Punctured 310 Ripped or Torn 312 Torn Off or Damaged 313 Vented Code Cause(s) of Failure 501 Abrasion 502 Broken Component or Device 503 Commodity Self-ignition 504 Commodity Polymerization 505 Conveyer or Material Handling Equipment Mishap 506 Corrosion – Exterior 507 Corrosion – Interior 508 Defective Component or Device 509 Derailment 510 Deterioration or Aging 511 Dropped 512 Fire, Temperature, or Heat 514 Freezing 515 Human Error 517 Improper Preparation for Transportation 520 Inadequate Maintenance 521 Inadequate Preparation for Transportation 522 Inadequate Procedures 523 Inadequate Training 524 Incompatible Product 525 Incorrectly Sized Component or Device 526 Loose Closure, Component, or Device 527 Misaligned Material, Component, or Device 528 Missing Component or Device 529 Overfilled 530 Overpressurized 531 Rollover Accident 536 Vandalism 537 Vehicular Crash or Accident Damage Bulk Tank Vehicles—Cargo Tank Motor Vehicles (CTMV) and Tank Cars Code What Failed 101 Air Inlet 105 Bolts or Nuts 106 Bottom Outlet Valve 107 Check Valve 110 Cover 115 Discharge Valve or Coupling 116 Excess Flow Valve 117 Fill Hole 118 Flange 119 Frangible Disc 120 Fusible Pressure Relief Device or Element 121 Gasket 122 Gauging Device 123 Heater Coil 124 High Level Sensor 125 Hose 126 Hose Adaptor or Coupling 127 Inlet (Loading) Valve 131 Lifting Lug 132 Liner 133 Liquid Line 134 Liquid Valve 135 Loading or Unloading Lines 136 Locking Bar 137 Manway or Dome Cover 138 Mounting Studs 139 O-Ring or Seals 141 Piping or Fittings 142 Piping Shear Section 143 Pressure Relief Valve or Device - Non- Reclosing 144 Pressure Relief Valve or Device - Reclosing 145 Remote Control Device 146 Sample Line 147 Stub Sill (Tank Car) 148 Sump 149 Tank Head 150 Tank Shell 151 Thermometer Well 152 Threaded Connection 153 Vacuum Relief Valve 154 Valve Body 155 Valve Seat 156 Valve Spring 157 Valve Stem 158 Vapor Valve 159 Vent 160 Washout 161 Weld or Seam Code How Failed 301 Abraded 302 Bent 303 Burst or Ruptured 304 Cracked 305 Crushed 306 Failed to Operate 307 Gouged or Cut 308 Leaked 309 Punctured 310 Ripped or Torn 311 Structural 312 Torn Off or Damaged 313 Vented Code Cause(s) of Failure 501 Abrasion 502 Broken Component or Device 503 Commodity Self-ignition 504 Commodity Polymerization (Continued on next page)#

Attachment 1, passage 13Failure Codes by Packaging Type Bulk Tank Vehicles—Cargo Tank Motor Vehicles (CTMV) and Tank Cars Code Cause(s) of Failure 505 Conveyer or Material Handling Equipment Mishap 506 Corrosion - Exterior 507 Corrosion - Interior 508 Defective Component or Device 509 Derailment 510 Deterioration or Aging 511 Dropped 512 Fire, Temperature, or Heat 515 Human Error 517 Improper Preparation for Transportation 518 Inadequate Accident Damage Protection 519 Inadequate Blocking and Bracing 520 Inadequate Maintenance 521 Inadequate Preparation for Transportation 522 Inadequate Procedures 523 Inadequate Training 524 Incompatible Product 525 Incorrectly Sized Component or Device 526 Loose Closure, Component, or Device 527 Misaligned Material, Component, or Device 528 Missing Component or Device 529 Overfilled 530 Overpressurized 531 Rollover Accident 532 Stub Sill Separation from Tank (Tank Cars) 533 Threads Worn or Cross Threaded 536 Vandalism 537 Vehicular Crash or Accident Damage Incident Reporting Requirements § 171.15 Immediate notice of certain hazardous materials incidents. (a) General. As soon as practical but no later than 12 hours after the occurrence of any incident described in paragraph (b) of this section, each person in physical possession of the hazardous material must provide notice by telephone to the National Response Center (NRC) on 800- 424-8802 (toll free) or 202-267-2675 (toll call). Notice involving an infectious substance (etiologic agent) may be given to the Director, Centers for Disease Control and Prevention (CDC), U.S. Public Health Service, Atlanta, Ga., 800-232-0124 (toll free), in place of notice to the NRC. Each notice must include the following information: (1) Name of reporter; (2) Name and address of person represented by reporter; (3) Phone number where reporter can be contacted; (4) Date, time, and location of incident; (5) The extent of injury, if any; (6) Class or division, proper shipping name, and quantity of hazardous materials involved, if such information is available; and (7) Type of incident and nature of hazardous material involvement and whether a continuing danger to life exists at the scene. (b) Reportable Incident. A telephone report is required whenever any of the following occurs during the course of transportation in commerce (including loading, unloading, and temporary storage): (1) As a direct result of a hazardous material— (i) A person is killed; (ii) A person receives an injury requiring admittance to a hospital; (iii) The general public is evacuated for one hour or more; (iv) A major transportation artery or facility is closed or shut down for one hour or more; or (v) The operational flight pattern or routine of an aircraft is altered; (2) Fire, breakage, spillage, or suspected radioactive contamination occurs involving a radioactive material (see also § 176.48 of this subchapter); REPORTING REQUIREMENTS • 11 (3) Fire, breakage, spillage, or suspected contamination occurs involving an infectious substance other than a diagnostic specimen or regulated medical waste; (4) A release of a marine pollutant occurs in a quantity exceeding 450 L (119 gallons) for a liquid or 400 kg (882 pounds) for a solid; or (5) A situation exists of such a nature (e.g., a continuing danger to life exists at the scene of the incident) that, in the judgment of the person in possession of the hazardous material, it should be reported to the NRC even though it does not meet the criteria of paragraph (b) (1), (2), (3) or (4) of this section. (c) Written report. Each person making a report under this section must also make the report required by § 171.16 of this Subpart. Note to § 171.15: Under 40 CFR 302.6, EPA requires persons in charge of facilities (including transport vehicles, vessels, and aircraft) to report any release of a hazardous substance in a quantity equal to or greater than its reportable quantity, as soon as that person has knowledge of the release, to DOT’s National Response Center at (toll-free) 800-424-8802 or (toll) 202-267-2675. § 171.16 Detailed hazardous materials incident reports. (a) General. Each person in physical possession of a hazardous material at the time that any of the following incidents occurs during transportation (including loading, unloading, and temporary storage) must submit a Hazardous Materials Incident Report on DOT Form F 5800.1 (01-2004) within 30 days of discovery of the incident: (1) Any of the circumstances set forth in § 171.15(b); (2) An unintentional release of a hazardous material or the discharge of any quantity of hazardous waste; (3) A specification cargo tank with a capacity of 1,000 gallons or greater containing any hazardous material suffers structural damage to the lading retention system or damage that requires repair to a system intended to protect the lading retention system, even if there is no release of hazardous material; or (4) An undeclared hazardous material is discovered.#

Attachment 1, passage 1412 • REPORTING REQUIREMENTS (b) Providing and retaining copies of the report. Each person reporting under this section must— (1) Submit a written Hazardous Materials Incident Report to the Information Systems Manager, PHH- 63, Pipeline and Hazardous Materials Safety, Department of Transportation, Washington, DC 20590-0001, or an electronic Hazardous Material Incident Report to the Information System Manager, PHH-63, Pipeline and Hazardous Materials Safety Administration, Department of Transportation, Washington, DC 20590-0001 at http://hazmat.dot.gov; (2) For an incident involving transportation by aircraft, submit a written or electronic copy of the Hazardous Materials Incident Report to the FAA Security Field Office nearest the location of the incident; and (3) Retain a written or electronic copy of the Hazardous Materials Incident Report for a period of two years at the reporting person’s principal place of business. If the written or electronic Hazardous Materials Incident Report is maintained at other than the reporting person’s principal place of business, the report must be made available at the reporting person’s principal place of business within 24 hours of a request for the report by an authorized representative or special agent of the Department of Transportation. (c) Updating the incident report. A Hazardous Materials Incident Report must be updated within one year of the date of occurrence of the incident whenever: (1) A death results from injury caused by a hazardous material; (2) There was a misidentification of the hazardous material or packaging information on a prior incident report; (3) Damage, loss or related cost that was not known when the initial incident report was filed becomes known; or (4) Damage, loss, or related cost changes by $25,000 or more, or 10% of the prior total estimate, whichever is greater. (d) Exceptions. Unless a telephone report is required under the provisions of § 171.15 of this part, the requirements of paragraphs (a), (b), and (c) of this section do not apply to the following incidents: (1) A release of a minimal amount of material from— (i) a vent, for materials for which venting is authorized; (ii) the routine operation of a seal, pump, compressor, or valve; or (iii) connection or disconnection of loading or unloading lines, provided that the release does not result in property damage. (2) An unintentional release of hazardous material when: (i) The material is properly classed as— (A) ORM-D; or (B) a Packing Group III material in Class or Division 3, 4, 5, 6.1, 8, or 9; (ii) Each packaging has a capacity of less than 20 liters (5.2 gallons) for liquids or less than 30 kg (66 pounds) for solids; (iii) The total aggregate release is less than 20 liters (5.2 gallons) for liquids or less than 30 kg (66 pounds) for solids; and (iv) The material is not— (A) offered for transportation or transported by aircraft, (B) a hazardous waste, or (C) an undeclared hazardous material. (3) An undeclared hazardous material discovered in an air passenger’s checked or carry- on baggage during the airport screening process. (For discrepancy reporting by carriers, see § 175.31 of this subchapter.)#

Attachment 1, passage 15U.S. Department of Transportation Satetv Administration Hazardous Materials Incident Report Form Approval OMB No. 2137-0039 INSTRUCTIONS: Submit this report to the Information Systems Manager, U.S. Department of Transportation, Pipeline and Hazardous Materials Safety mandatory and will take 96 minutes to complete the Office of Hazardous Materials Website at http://hazmat.dot.gov. If you have any questions, you can contact the Hazardous Materials Administration, Office of Hazardous Materials Safety, PHH-63, Washington, D.C. 20590-0001. If space provided for any item is inadequate Information Center at 1-800-HMR-4922 (1-800-467-4922) or online at http://hazmat.dot.gov. use a seperate sheet of paper, identifying the entry number being completed. Copies of this form and instructions can be obtained from PART I - REPORT TYPE 1. This is to report: Al A hazardous material incident • BI An undeclared shipment with no release PART II - GENERAL INCIDENT INFORMATION 2. indicate whetner Inis Is. An initial report A supplemental (tollow-up) report • Additional Pages 3. Date of Incident: 5. Enter National Response Center Report Number (if applicable): 4. Time of Incident (use 24-hour time): 7. Location of Incident: City: 6. If you submitted a report to another Federal DOT agency, enter the agency and report number: Street Address/Mile Marker/Yardname/Airport/Body of Water/River Mile - County: — State: ZIP Code (if known): 9. Transportation Phase 8. Mode of Transportation In Transit • Highway Loading • Rail 10. Carrier/Reporter Unloading Water Name In Transit Storage Street Federal DOT ID Number City Hazmat Registration Number State — _ ZIP Code, 11. Shipper/Offeror Name 12. Origin Waybill/Shipping Paper City Street _ State . it different from City Street Hazmat Registration Number _ ZIP Code 13. Destination City Street State . ZIP Code 15. Technical/Trade Name: 14. Proper Shipping Name of Hazardous Material: State ZIP Code 16. Hazardous Class/ Division: 17. Identification Number: 10.9. UN2764, NA 20201 18. Packing (if applicable) Group: 19. Quantity Released: 20. Was the material shipped as a hazardous waste? • Yes • No If yes, provide the EPA Manifest Number: (Include Measurement Units) 21. Is this a Toxic by Inhalation (TIH) material? 22. Was the material shipped under an Exemption, Approval, or Competent Authority Certificate? • Yes • No If yes, provide the Hazard Zone: If yes, provide the Exemption, Approval, or CA number: • Yes • No 23. Was this an undeclared hazardous materials shipment? • Yes • No Form DOT F 5800.1 (01-2004) Page 1 Reproduction of this form is permitted Untitled-s 09/15/2005, 11:02 AM#

Attachment 1, passage 16PART III - PACKAGING INFORMATION 24. Check Packaging Type (check only one - if more than one, list type of packaging, copy Part III, and complete for each type: • Non-bulk • Cvlinder • IBC • RAM • Carao tank Motor Vehicle (CTMV) • Portable Tank • Tank Car • Other 25. See instructions and enter the appropriate failure codes found at the end of the instructions. Be sure to enter the codes from the list that corresponds to the particular packaging type checked above. Enter the number of codes as appropriate to describe the incident. Enter the most important failure point in line 1. If there are more than two failure points, provide in this format in Part VI. 1. What Failed: 2. What Failed: How Failed: How Failed: Causes of Failure: Causes of Failure: 26a. Provide the packaging identification markings, if available. Identification Markings: 26b. For Non-bulk, IBC, or non-specification packaging, if identification markings are incomplete or unavailable, see instructions and (Examples: 1A1/Y1.4/150/92/USA/RB/93/RL, UN31H1/Y0493/USA/M9339/10800/1200, DOT - 105A - 10OW (RAIL), DOT 406 (HIGHWAY), DOT 51, DOT 3-A) complete the following: Packaging Type: Single Package or Outer Packaging: Single Package or Inner Packaging (if any): Head Type (Drums only): Material of Construction: Packaging Type: • Removable • Non - Removable Material of Construction: 27. Describe the package capacity and the quantity: Package Capacity: Single Package or Outer Packaging: Single Package or Inner Packaging (if any): Number in Shipment: Amount in Package: Amount in Package: Package Capacity: Number Failed: Number in Shipment: Number Failed: 28. Provide packaging construction and test information, as appropriate: Manufacturer: Material of Construction: Serial Number: Manufacture Date: Last Test Date: _ Design Pressure: lif Tank Car, CTMV, Portable Tank, or Cylinder) Shell Thickness: (if Tank Car, CTMV, Portable Tank) Head Thickness (if Tank Car, CTMV) lif Tank Car, CTMV, Portable Tank) If valve or device failed: Service Pressure: (if Cylinder) Type: — Manufacturer: Model: 29.If the packaging is for Radioactive Materials, complete the following: (if present and legible) (if present and legible) Packaging Category: Packaging Certification: • Type A Nuclide(s) Present: • Self Certified • U.S. Certification • Type B • Type C I Exceptod O indust Activity: _ Critical Safety Index: Transport Index: rtification Num Form DOT F 5800.1 (01-2004) Page 2 Reproduction of this form is permitted Untitled-2 09/152005. 11:02 AM#

Attachment 1, passage 17PART IV - CONSEQUENCES 30. Result of Incident (check all that apply): • Spillage • Vapor (Gas) Dispersion • Environmental Damage • Fire • Explosion • Material Entered Waterway/Storm Sewer 31. Emergency Response: The following entities responded to the incident: • Fire/EMS Report # • Police Report # neck all mat abov. • No Release • In-house cleanup • Other Cleanup 32. Damages: If yes, enter the following information: Was the total damage cost more than $500? Material Loss: If no, go to question 33. • Yes • No Property Damage: Response Cost: Remediation/Cleanup Cost: 33a. Did the hazardous material cause or contribute to a human fatality? See damage detinitions in the instructions) Fatalities: If yes, enter the number of fatalities resulting from the hazardous material: • Yes • No Employees Responders General Public 33b. Were there human fatalities that did not result from the hazardous material? 34. Did the hazardous material cause or contribute to personal injury? D Yes • No If yes, how many? If yes, enter the number of injuries resulting from the hazardous material: • Yes • No Non-Hospitalized: Hospitalized (Admitted Only): Employees Employees Responders (e.g.: On site frst aid or Emergency Room observation and release) Responders General Public General Public 35. Did the hazardous material cause or contribute to an evacuation? If yes, provide the following information: • Yes • No Duration of the evacuation Total number of general public evacuated - (hours) Total number of employees evacuated Total Evacuated 37. Was the material involved in a crash or derailment? 36. Was a maior transportation arterv or facility closed? • Yes • No If yes, how many? _ If yes, provide the following information: Vehicle overturn? Estimated speed (mph): • Yes • No _ (hours) • Yes • No Weather conditions: Vehicle left roadway/track? • Yes • NO PART V - AIR INCIDENT INFORMATION (please refer to $ 175.31 to report a discrepancy for air shipments) 38. Was the shipment on a passenger aircraft? If ves, was it tendered as cargo, or as passenger baggage? • Yes • No 39. Where did the incident occur (if unknown, check the appropriate box for the location where the incident was discovered)? • Cargo • Passenger baggage • By surface to/from airport • Air carrier cargo facility • During flight • Sort center • Baggage area 40. What phase(s) had the shipment already undergone prior to the incident? (Check all that apply) • During loading/unloading of aircraft • Initial transport by highway to cargo facility • Transfer at sort center/cargo facility • Shioment had not been transported • Transported by air (first flight) • Transport by air (subsequent flights) Form DOT F5800.1 (01-2004) Page 3 Reproduction of this form is permitted Untitled-? 09/15/2005. 11:02 AM#

Attachment 1, passage 18IL PART VI - DESCRIPTION OF EVENTS & PACKAGE FAILURE ine auration or ine release, u possipie. Descripe war was done to mugate ine enecis or te release. Continue on adanional sneets m Describe the sequence of events that led to the incident and the actions taken at the time it was discovered. Describe the package failure, necessary. including the size and location of holes, cracks, etc. Photographs and diagrams should be submitted if needed for clarif cation. Estimate PART VII - RECOMMENDATIONS/ACTIONS TAKEN TO PREVENT RECURRENCE Where you are able to do so, suggest or describe changes (such as additional training, use of better packaging, or improved operating procedures) to help prevent recurrence. Provide recommendations for improvement to hazardous materials transportation beyond the control or vour inalvidual comoany. conunue on adoltional sneers iT necessary. PART VIII. CONTACT INFORMATION Contact's Name (Type or Print): Contact's Title: Telephone Number: |) Business Name and Address: Hazmat Registration Number (if not already provided): Fax Number: ( Preparer is: E-mail Address: • Carrier • Shipper • Facility Date: • Other Form DOT F 5800.1 (01-2004) Page 4 Reproduction of this form is permitted Untitled-2 09/152005. 11:02 AM#

Attachment 1, passage 19Incident Reporting Guidelines • 17 This Page Intentionally Left Blank EFFECTIVE JANUARY 1, 2005 HAZARDOUS MATERIALS INCIDENT REPORTING AND REQUIREMENTS U.S. Department of Transportation Pipeline and Hazardous Materials Safety Administration 400 Seventh Street, S.W. Washington, DC 20590 FIRST-CLASS MAIL POSTAGE & FEES PAID PIPELINE AND HAZARDOUS MATERIALS SAFTEY ADMINISTRATION PERMIT NO. G-126#