ENVIRONMENTAL INCIDENT REPORT

Name of Establishment:

Address:

Name of Managing
Head:
Name of PCO:

Date of Incident:

Time of Incident:

Type of Incident:
o Breakdown of wastewater treatment plant
o Breakdown of air pollution control device
o Release of chemicals to environment media
o Release of hazardous waste to environment media
o Exceedance to effluent standards
o Exceedance to emission standards
o Others, please specify
Description of Incident:

Estimated Amount of Chemicals, Hazardous Wastes, Emissions, and /or Effluent Released to the
Receiving Environment:

Probable Cause of the Incident:

Interim Contingency Measures to Mitigate Any Potential Negative Impacts:

Completed by: Date:

(Name and Signature of PCO)
Completed by: Date:
(Name and Signature of PCO)
Note: Corrective Actions to prevent recurrence, estimated amount pf the needed recovery/repair/ clean-up and estimated date
of completion for any needed repairs should be reflected in the next submission of the SMR.