ADEM Incident Report

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Name of Person Requesting:  
Organization/Agency:  
Contact Number:  



Incident Type:
Has incident been previously reported?     
Type in the incident number if known:
Incident Location:
County:
City:
Exact Location:
Roadway Blocked?    
Highway/Street Name:

Date Occurred:
Time Occurred:

Hazardous Material(s): Quantity:

Waterways Affected?    
Name/Location of Affected waterways:
Is affected waterway a public water source?    
Is wildlife endangered/threatened?    

Vehicle Type:
Specify Driver Injury:

Owner Name:
Address:
Contact #:
Has the owner been notified?    
Name of environmental cleaup company:
Address:
Contact #:

Evacuation
Has the incident area been evacuated?    
Number of people evacuated:
Description of evacuated area:
Shelter Open?    
Shelter Location:
Number of people sheltered:
Red Cross notified?    

Emergency Response
Arkansas State Police:
Arkansas Highway Police:
ADEM:
County Sheriff's Office:
City Police Department:
ADEQ:
State Health:
Arkansas Game and Fish Commission:
Ambulance/EMT:
Highway Department:
Fire/Rescue:
Environmental Cleaup Company:
Company Representative/Responsible Party:
Has National Response Center been notified?
   
Name of Environmental Cleanup Company:
Name of company representative/responsible party:

Assistance Requested:

Brief Description/Comments:
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