ADEM Incident Report

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1. Incident Type: Has Incident been previously reported?     No     Yes Select Incident Type from List Accident River Animal Disease Emergency Aviation Security Bomb Threat Downed Aircraft Civilian Downed Aircraft Military Drowning Earthquake Emergency Locator Transmission Fire Forest Fire Structure Flood Impact Hazmat Air Hazmat Disposal Site Hazmat Fixed Facility Hazmat Highway Hazmat Landfill Hazmat MFG Hazmat Misc Hazmat Pipeline Hazmat Rail Hazmat Refinery Hazmat River Hazmat Storage Hazmat Stream Hazmat Waste Highway Accident Ice Storm Impact Lost Person Miscellaneous Impact Nuclear Non-Fixed Nuclear Fixed PBA 1/2 PBA 3 PBA 4 Pipeline Accident RADMAT Movement Terrorism Event Thunderstorm Impact Tornado Impact Train Accident Utility Failure (Power) Water Shortage * Type in the Incident # (if known):

2. Incident Location: County:  Select County from List Arkansas Ashley Baxter Benton Boone Bradley Calhoun Carroll Chicot Clark Clay Cleburne Cleveland Columbia Conway Craighead Crawford Crittenden Cross Dallas Desha Drew Faulkner Franklin Fulton Garland Grant Greene Hempstead Hot Spring Howard Independence Izard Jackson Jefferson Johnson Lafayette Lawrence Lee Lincoln Little River Little Rock Logan Lonoke Madison Marion Miller Mississippi Monroe Montgomery Nevada Newton North Little Rock Ouachita Perry Phillips Pike Poinsett Polk Pope Prairie Pulaski Randolph Saline Scott Searcy Sebastian Sevier Sharp St. Francis Stone Union Van Buren Washington White Woodruff Yell   * Roadway Blocked?     No     Yes City:  * Highway/Street Name: Exact Location:

3. Date Occurred:                 * Time Occurred:

4. Hazardous Material(s):  Quantity:

5. Waterways affected?     No     Yes Name/Location of Affected Waterway:   Is wildlife endangered/threatened?     No     Yes Is affected waterway a public water source?    No     Yes

6. If Incident is traffic related, give detailed vehicle information: Vehicle Type:  Select Vehicle Type from List Aircraft - Civilian Aircraft - Military Bus - Private Carrier Bus - Public Transport Commercial Truck Passenger Vehicle - Car Passenger Vehicle - Truck Train Tractor/Trailer Specify Driver Injury: Minor Injury - No Transport Major Injury - Transported to Hospital Fatality Owner's Name: Address: Contact #: Has Owner been notified?     No     Yes Name of Environmental Cleanup Company contracted to clean up the incident scene: Address: Contact #:

7. Evacuation Has the incident area been evacuated?     No     Yes Number of people evacuated:  Enter a description of the evacuated area: Shelter Open?     No     Yes Shelter Location:  # People Sheltered:  Red Cross Notified?     No     Yes

8. Emergency Response: Arkansas State Police Notified On the Scene Arkansas Highway Police Notified On the Scene ADEM Notified On the Scene County Sheriff's Office Notified On the Scene City Police Department Notified On the Scene ADEQ Notified On the Scene State Health Notified On the Scene Arkansas Game and Fish Commission Notified On the Scene Ambulance/EMT Notified On the Scene Highway Department Notified On the Scene Fire/Rescue Notified On the Scene Environmental Cleanup Company Notified On the Scene Company Representative/Responsible Party Notified On the Scene Has National Response Center been notified?     No     Yes

9. Assistance Requested:

10. Brief Description/Comments: