Continuous Release Reporting Form 

Fom1 Approved OMB No. 2050-0086 

Expiration Date: XX-XX-XXXX 

SECTION I: GENERAL 

INFORMATION CR-ERNS Number: I 

I I Date of Initia l Call to NRC: I ~--------------~==========~ 

Date oflnitial Release: 

Type of Report: Select tfom the drop-down list, I 

the type of report that you 

are submitting 

Signed Statement: I certify that the hazardous substance releases described herein are continuous and stable in quantity 

and rate under the definitions in 40 CFR 302.8(a) or 355.32 and that all submitted information is accurate and current to the 

best of my knowledge. 

Dare Name and Position 

Part A. Facility or Vessel Information 

Name of Facility or Vessel 

Person in Charge 

of Facility or 

Vessel 

Name 

Phone Number 

Street 

Signature 

Position 

Alt Phone No. 

County Facility Address 

or Vessel Port of 

Registration City ...__ _____ _, State D ZipCodc'-l ____ _,l 

Dun and Bradstre et Number for Facility I 

Facility Nessel 

Location 

Latitude Dcg 0 Min O see 0 Vessel LORAN Coordinates 

Longitude Dcg 0 Min O see 0 

NOTE: Larirude!Longiwde information can be obtained ar tlte following websires: ltup:llwww.smsig.net/mops/lat·long-fmder.htm. hup:l/earth.goog co l. 

and ltup:!ill'll'll'.censrrs.gol·lgeolland,·iewl. Do not use P.O. Box. Rural Rowe or Mailing Address. Use physical/ocarion only. 

Part B Population Information 

Population 

Density 

Se lect from the drop-down list, the range that I 

descri bes the population density within a onemile radius of your facility or vessel. 

Sensitive 

Populations and 

Ecosystems within 

One-Mile Radius 

Sensitive Populations or Ecosystems Estimated Distance and Direction from 

(e.g .. elementary schools. hospitals, retirement communities, Facility, if Known 

or wetlands) 

I I 

EPA Fonn 6100-1 0, Continuous Release Reporting Form Page I of 
INSTRUCTIONS 

SECTlON 1: GENERAL INFORMATION 

Cll-F:RNS Numbrr: 

If you art! rt!porung a reletl.<<' of a C£RCL,I ho:ardou.< s ub.<tanu{s). )'OIIIItll be nsstgned o CR-ERNS number uhen you mnlce tlus mil tal telephone call to the 1\'RC 

0-811n-.fl-l-cY80l) 71us CR-ERNS number 1111/ became the tdentifier far your fnctllly Your Cll-ERNS 1111111her ll'tllne•·er change: 11 t.f the number that tdentifie.< )'OIIIfl 

the CR-£RNS databnu. 

The mformation reqwred 111 Section I of the illltWIII'rtllen repor1 and follvw-up reports includes genera/mformation idemifying your faCility. as well as mformallon 

rl!garding thl! are11 m which ynurft~cili ly t.r loca1ed. 77u.r generalmformallou is tmportant because if provide.< a be tier wtderslanding of the potenllal nslcs resulting 

/rom exposure from the facillly'.r release. A signed .flateme/11 assertmg lhalthe contmuous release t.r coniiiiiiOllS and s1able in quanllty and rtlle. and thai the 

mformnnon s upplu:d IS accur(l(e and currelllto the hest of your lcnowh:dge. IS also reqwred in Secuon I. 

In add111on. SecuonlniiJSI clearly tdentify the t;pe ofwrmen report/hat you are .rubmillmg (i.e .. an 11111/a/wmlm repon. a first amu•·ersaryfollow-up reporl. or a 

11 rllten report of the change m source or compos111on of a prel'lor;s/y reported release). You must also me/rule m/omration 011 tire mil tal notification of tire reletue . 

. weir as tire date of tire relea.re and tire dale of tire 1111110/ call. For ('1-."RCI.A lra:nrdous suh.<tancn tire CR-ERNS munher ass1g11ed to you by tire NRC wtll also be 

reqr11red. 

Type of Report - Select from drop-dow111ist. 

Initial Wrillrn Notilicntion • Witlun 30 days of the mllwlteleplro11e 11ottjicallo11. 

you are reqwred to s ubmll an uuualwr111e11 report to tire appropriate EPA 

Regtmwl Office. SERC. a11d LEPC {for releases o/CERCLA lra=ardou.t 

sub.rtances) omlto only tire appmprwte S£RC mrd 1.1-."I'C (for releases of IIOII· 

CERCI.A £1/Ss) 71re purpose of/Ius report I.< ta confirm your mtemto report 

your release as a callllllliOIIS release under Sec/1011 103(/)(2). a11d to prowde 

go,·erm11ent respo11se officials witlr .wfficielltmformollnn about your release to 

cmablf! tlrem to de term me if the release qualifies os a cammuous rclea.H!. 

First Annivrr~a y Follow-up Report · For reports of releases ofC£RCLil 

lra:ardous subsumcl.'s. w1tlrin 30 days of tire first tmn11•er.mry of your 1111/lalll·rme11 

report. you are reqwred to reassess your milia/ conti11uous release report nntl 

gather tire mformauon on all of tire repor1cd sub.flnnces bemg released After 

domg tlus. you niiLII suhm11 a one-time wnl/en first amlll'ersary• follow-up report to 

the appropnate El' A Regw11al Office. !'lease note tlrattlre first amuversary reporl 

11111.</ be semto tire appropriate EI'A Regmnal Office for all reports ofC/iRCIA 

/w:ardous .wb.<tances. bill is not required for report.< ofnon-C£/?CLA EllS.<. 

Written No tilication of 11 Change to l nitinl No tilication and/or Writt en Notilir:llion of a Change to Follow-upllcportI NOTE: For these reports. select the report type that reflects the notrlicatron or report lor which you arc rcportrng a change] 

Notificatwn of a cham:e msvum· or COIIIf]lUil.IJI.IJ.. uluch t.f treated as tj1111ere a11e11 release {t.l.' .. u-uh a telephone call to the NRC. SERC. and LEPC.followed by 

a llrtl/en report and a first amri•·ersary•folluu -up report). 

= N01tjication of a cham:c 111 tbe nonna/ range if thue 1.r a change 111 the relea.re .filch 1/rar the quail///)' of the releau exceeds the uppu bou11d of tire reported normal 

range. the release 1111/.JI he reported a.t a stat!.<IC(IIIv stgnifictmt increa.<e. 

- For rERCLA subslcmces only. 1/0tijication of (Ill)' a!lu:r..a:ported jnjOI"IIlCJl.JJJJJ r~ g .. a change infactllly OWIII!I"Slrip) in (I wnllen feller to only lire EI'A Region. 

t'11r1 A. F:tcitity or Vr~srl lnf rrnnlion

I. Tire complete n11111e tifyour facility (and company ulentifier wlrae appmprmte). lfmultiplefacilities arc mcluded 111 your Written report. provule tire plant.<tte 

name ll'ith the name oftlrefaciluy. 

2. Tire full address of your fact lily. mc/udmJ( tire .<tree/ address or lugl111'a)' marker. city. county. Stille. and :tp cad.:. A pn<l office box number slwulclnot be u.retl 

as the factllly address. 77re address prnwded .<hould be tire location of the faci/lly where tire lm:ardous s ubstance release occurs 

3. Tire locatton of your faethty by II.< lallttule and /onguude in rmm nf dej:reer. minutes. and second< Su below for helpfulluntr on/row to obwmthe lalllltde 

a11d longitude cuordmate.r of your fact illy. 

-1. The m11e dig1111111nbcr as.<tgned by Du11 a11d !Jrt~d tre t (D& B) to yourjircthty. Tlus nwnber can bf! obtomf!d via telephone by 011 officer of your company 

fi"omthe nallonal office o/Drm a11d /Jrad.rtreet (at/-800-23-1-3867) If your facilily lras nlll been assigned a D&/1 number. please .rpecify 1lw11he mformallon 

is nol appltcable. illtf• """ ".clnh com / .\ """' "''"""' 

5. For reports ofCERCI.il ha:ardous substance.r. the Cll-ERNS mJmher a.mgned by thl! NHC uhen you made the milia/telephone report. Be cerwinto 111clude 

the CR-ERNS number on fJK.hpage of your report 

6 Tire name. telephone 1111111ber {mcludmg area code). and an alternate telepho11e number for the person m charge of your faCIIIIy. 

SO HCES OF ~FO R~ A TION FOR IDE 'TIFYING TilE LOCATION Of YOUR FACILITY 

Source.r of daw on latllude amllnng11ude coordmate.r of your faet!tty mclude £/'A permll.r (e.g .. NI'DES permnr). couaty property records. factltty blueprmts. aml.we 

plan.r In addiuon. 'urfomuwnn 011 1he latllude a11d lo11glllule of your faCility may he obtmned from a Umtcd Slates GeologiCal Sun•ey (USGS) topograplucalmap 

71tc.<e maps arc arm/able 111 hoth the 7.5 nunule and 15 1111111111.' scncs. 71wse maps may be obtained ji·om the USGS distribwion center at your local public ltbrary. If 

)'OUIIOuld like to order a mapfi"om USGS. contocr U.S. Geological Swwy - l•rformation Services. Box 25286. Dem·er. CO 80225. ca/11-888-ASK-USGS 

(1-888-275-8747}/llltJ• It/nan '".1:' .\:" ~" "'''''''"!.' luml 

If you are not certain onwluch map your stte '-' located. consult the mdex Jtj topographic maps for your .rtate. wluch may be obtamed from USGS free of charge. 

usc;s maps are also al"lulable at commercial dealers suclr as .tun•eyors or owdoor rureatwn eqwpmem dealers 

I tlltlltrll' I tmgllutl ... · tn{fiiiiiU/Icm om lw ohratnctl til tlu {ollouun: uc:hHh'\ hllp \11111 ft/1\(l: llf i iiM/t\ lnt-ltmg-fiudt·r_/llm. h11p. c'tllllt _'.!t'n•,•/,• t·om. uud hiiJI u u '• 

< , -fl\11' gc•t \!'~·n ffiUtf\ h'U 

l'art II. Population Information · 

I Choose the range fi"om I he drop down list. the nmge thm mo.fl acntratcly descnbl's the popultllton denslly willrin o one-11ule radius of your fact!tly. 

l . ldemify and dc.<erihe the local/on of a11y sensitive populmions or c:cosy.<tem.< withi11 a one·mtle radmr ofyour facility . lfpo.r.<iblc. describe the locotwn tr/ the 

populanons or et:osystems 111 terms af thstmrce and direction from your faetlity (e.g .. located !/, mtle nortlrwesl of tire factllly). £.tact addresses are not 

reqwred. 

Snrsith·t' popul11tionr • populnuon.r hlcely to b., morc: su..teepuhle than lll"c:rage lltthl"llluals to the effects of I!XfJO.wre w a lta:artloas sub.<tnnce. Examples of St.'IISIIII"e 

populauons are dcmentar)' school c/11/dren. rctm:melll conunulllllt'.<. or hospttals 

s~ <iti• ~ ~cosys s - cm•tronmcms ltkl.'iy tube mnrc sllscepllblc: than u•·em,11e cm ~ronmems 10 the effects of exposure to alw:artlai/S substance. ar ecosystems that 

haw: heen destgnat.:d fnr .rpecml protection hy Federal or state gm·ernmcm.• Example of.<eiiStiii'C eco.<yslcm.< Includes wetlands 
Continuous Release Reporting Form 

Fonn Approved OMB No. 2050-0086 

Expiration Date: XX-XX-XXXX 

SECTION II: SOURCE 

I I INFORMATION CR-ERNS Number: 

Part A: Basis for Asserting the Release is Continuous and Stable in Quantitx and Rate. 

For EACH source of a release of a hazardous substance or mix ture from your facility or vessel, provide 

the following information on a SEPA RA TE sheet. 

I Name of Source: I 

I. Indicate whether the release from this source is either: 

0 Continuous without intcrn1ption OR O routine, anticipated. intennittcnt & incidental to 

Note that unanticipated events, such as spills, pipe ruptures, equipment failures, emergency shutdowns, or 

accidents, do not qualify .for reduced reporting under CERCLA section I 03(/)(2). Unanticipated events are 

not incidental to normal operations and, by definition, are not continuous or anticipated, and are not 

sufficiently predictable or regular to be considered stable in quantity and rate. 

2. Provide a brief statement describing the basis for stating that the release is continuous and stable in quantity and rate. 

If malfunction, describe the malfunction and explain why the release from the malfunction should be considered 

continuous and stable in quantity and rate given the note above. 

3. Identify below how you established the pattem or release and calcu lated release estimates. 

O Release data OKnowledge of Operating Procedures 0 Engineering estimate O Best Professional judgment 

OtherEPA Fom1 6 I 00- I 0, Contmuous Release Reportmg Fom1 

Page or 

II 

I 
INSTRUCTIONS 

SECTION II: SOURCE INFORMATION 

(Part A) 

CR-ERNS Number: 

{(you are reporting a release of a CERCLA hazardous sulwam:c{.1), you will be assigned a CR-ERNS mtmber when you make this 

initial telephone call to the NRC (1-800-424-8802). This CR-ERNS munher will become the ident(/ier for your.facility. Your CRERNS number will never change: it is the number thai idenli[ics you in the CR-£RNS dalahase. 

Genera/ overview - When completing your wrillen report.s. you must toke imo con.<idcrotion all source.,· oj the release from yoru)ut·ility. 

Pro,,iding thu· informn/1011 liCLIIralefy in the lltillnl 

"t'tllrn tmdfirst anui,•er.,an • falfaw-up repnrt .,;(( minimi:e f uture request< b•• EPA far additional mformatwn or clarification. 

/11 thi.< scction of the wrillen report. you should ulentify and tlescrihc ,,·eporatcly flJ£h m minuous rclcasc If the continuous release of thc same ha:arclow· 

substance come.< from two or more .murces (e.g .. tu·o stacks). then informutiou .<lwuld be reported seportllcfy for J:tJ&h. of the sources. Fnr example. if a swck i.,. one of 

,\'I'VI:rol sources of a Jwwrtlou.< sub.<tance release at yourfacility . you must provide il!formmion on that stack including: the stack height: the identity of the lwwrdou,,· 

.wbsttmcc(s) being relea.wd from the stack: the qua11tity released: and the ji-equcnq of the release from the stuck. If you hove a re fl!tJ.<I! of a particular hawrduus 

substance from three stack.<, you should report mdJ_ .~tack .reparote~v ond pro••ide the required information specf/ied for each stock. 

Afthou~:h the contimtoU> relcMe reporting regulation alfows multiple concmrent ll!<~• ·.< aft he some CI!RCL;f lw:ardous substunce to be considered as if they were 

o11c cominuous releare. aggregate reporti11g of.mch releases from different .wun·c.t cnmplicotcs ri.<k a11aly.re.<. Area sources ore most readily aggregated jar purposes 

of ru11tinuou.< release reporting mrd risk ei'Oiuotiofl whe11 the jrequc11cy of the release from each source is the .wme. Similarly, aggregated stock releases are most 

readily evaluated if thefrequen'y of the release .from each stack i.r the some and rhe ,,·tack co11jigurationv (e.g .. stack height, diameter, throughput) are thl! same. {{you 

elect to aggregate releases ocro.u.facilities, be certointo identify injarmotiofl about mdJ_ source of the release .from olf of your.fad lities. Also. note that if you 

oggregote your release.<. Bf'1f may request clarifying it!formotion about the rclca.wsfmm each oft he individual murccs. 

Identification ofsmtrccs- In Section II. you must itlemify (i.e .. 11ame) o11d dl!.>crihe each contimwus releu.<e .<ortrcc. There are several woys 10 name relea:,e .w urce.r. 

It it important to (I) provtde o nome rhat dearly idemijie.< the source (e.g. ccmrifitgal proce.~<or A. mther than Unit A): and (Z) avoid giving 11\'o or more sources the 

.\time flame. It is also tmporltmtlo remember when naming your sourw.< that I:.'I'A. nt any time. may comaa J'fm with questions regarding releases from one of your 

aomcd source.<. It woutd be pmdcnl, therefore. to ntmre the .murces at your(tu·ctit)' in a manner that will be ea.<y fnr you and ather employees ta identifY them For 

cwmple, ifyour plam ha<four .<tack.<. rwo wastepile.<, and twenty-four vol•·cs. I'OU may name the source.< a.< {olfows: Stack # I: Swl'k #Z; Swck 113: Stack 114. Wa.rtepile 

Ill, Wastepile #1: wrtl Valves in OuildinJ< #1. Note thottlw .. Valves in lluiltfm~: Ill" are aggregated in thi.< ewmple o11d reported as o .<in}(le source. 

llriJIIlrrtl ;, p,rlltnlinn .. St•clion/1, Sourre ''!formulum. ( fiii/Uin.\' thl'(.'t! I'm'/,\ (l'f. n. mul C). Youmtt,\'l jJI'()V/tic the: injurmutioll r cqutt'Ctlllll!U(.'It of these I" uriS jorl:.aJ:h 

c·antimmus release .~o . /Je sure 10 place the nome o{the source on all puge.< o.<.<ncioted with thm spec:i/ic .wurce. There is one erccption tn this rule. lj thc reletw: 

from any indcvidtmf .wmrce wtlf u(fect more than tml.! envtrmuncntal ml!dium (e.g, o wastepile relea.<ing to oir and ground water) it mu.lf he modeled separately. 

Thcnfore. any source that affects two differcm medm .<hrmld he treated a.< two .n:parate source.< fur purpo.•es of reporting. 71cis iJ desirable bt:cuusc EPA must 

tma~v::e each relewe pathway separately to properly e••aluate the risks posed by the nmtinuous release:. In addition. because the hawrdous substance releose.< ta each 

mcdwm mt~\' differ in[rl!tfllency and quantity. it is we{ul w distinguL<h the rdea.H:.<.for purposes of ri.<k el'(1/uation. 

flrw A - Basis ((lr Asscai!IC! the llcka.•-r is Cawitlll!flts ami Stable in Ouallfi(J•_tl.11.!l../1Jm:.: 

You mu.vt }irs/ identify the .<mtrce of the relea.<e (im:ftule the twme of the source in olf .whscquent parts). then briefly describe the basis far .<fating that the release is 

1 ll11ti11uous and .<whlc in quantity and rare. )'our descri(Jfino of the ba.<is/or .Hating thuttlte hawrdous sulwmtce release is colllinmJ/IJ and stable in quantity and rote 

,,lwuld tncludc whether the rt.:kuse i.f continuuu.\' wttlumt interruption. or/,'( a rvuti11c. anticipated. intcrnullent release. It s hould al.fn inc·lude information un when the 

rt•fcme is <'xpected Ill 01 cur (i.e .. e••idencc ojpredl( wbilcty of rhc release) One ewmph• of a ref ell.< I.! that moy be predictable and regular is fugiti•'e em1sston.• jmm 

wtlw:s that occur at tltjferc•m mte.< ow:r the cour.<e ofo production cyde tt< the pre.<.<urc inside the system ( lwngcs Although the rate of such jugiti•·c ~<sion.< may 

not be .r:tric t(v uniform. II mn•• he predictable 111 the .'ft!llfl" that/he rate and amount nf the relt"tttc WU)' in u ,,·jmi/nr manner each time tire prncc.r:.r: is opercuet.l or 

dl't'nmpressiflll occur.f. 

Your de.fcriptionshould al.so identify the a~tivity thot re.wfls in the release (e ~: .. hmch process. operating procedure. adinglcmlood ~:. maintenance activity. jilfing 

of .<torogc tanks). If the relea.w: occurs hecatJSC ofamol(tmction. this should he CXfllained.fully. Note that o11fy ccrrnin releases due ro mafjimcrirms can '1""/i/j• a.< a 

r·nnrimuws refeose. Plea.<e rt'{er to the disc·11.uion in the prcnmhte ojtht• ccmti11uous release .filial rule ot .5.5 FR .10171, Jul. 14. 1990. 

Fmolly, your description shnrcld include it!formatirm tm /w11' you establish!'d the pal/em aj the release ami calculated relc:ose estimates (e.g .. engineering cstimmc.,, 

1'111/r bes1 projessiotwf judgment. past release data}. 

For each .<ourcc identified. provide thc.followinR in(tcrmaliOtr: 

(I) Indicate whether the rl!lea.re is continuous without intcrruplion or alwtclll('lll or routine. antidpotcd, und intermiuent. 

(Z) ldcnt{fy the activity or activities thot cmtsc the n:leo.\'c.fr(Jm the sourw. 

(.1) If the release results from n ma!fimction. describe the malfimction and explain why ,;,,. release should Ire ,-nn.<idercd 

continuous and stable in IJIItmtity and rate. 

(</) ldelll{fy how you established rhe paucm olthe rdea.<c and calculatecl rt:lease e.ffimmc.<. 
INSTRUCTIONS 

SECTION II: SOURCE INFORMATION 

(Part B) 

CR-ERNS Number : 

If you are reporting a relea:;e of a Ct;;I?CLA hazardous substance(\), you will be assigned a CR-D?NS number when you make this 

initial telephone call to the NRC (1 -800--12-1-8802). 'l11is CR-D?NS number will become the identifier for your facility. Your CRF.I?NS number will never change: it is the number that identifies you in the CR-EI?NS database. 

Part 8- S.p.J:s:.i./k.J.J.Jfomwtion on the Source: 

Yo u must identify the environmental medium (i.e .. air. swf ace water, soil, or ground wate!J affected by the hazardous substance 

release from 5W.f.h source identified in Section II, Part A. In addition. you must provide specific information on the source and its 

affected environme111. It is important to remember that if you have a release from a single source that affects two different media 

(e.g., gypsum stack releasing radon to air and radionuclides to ground wate!J. you should treat the release to each medium as a 

separate source for purposes of reporting. Another important poi111 to remember when completing all sections of the wrillen report 

is to include the appropriate units, such as kilograms. meters. or curies. 

Environmental medium -Identify the environmental medium (i.e .. air. swf ace water. soil. or ground water) that is affected by the 

relea~ e from the ide/1/ified source. 

I Air -((the medium affected is air. provide the following information. 

a. Indicate whether the source is a stack or ground-based area source. 

b. (f the source is a stack. provide the stack height in feel or meters. The stack height is the distance from the ground 

tv the top of the stack. 

c. If the source is an area source (e.g .. a waste pile. surf ace impoundment. landfill, valve. pump seal. or storage tank 

vem). provide an estimate of the swface area or area of the release source including the appropriate unit such as 

square feet, square meters. or acres. 

2. Surface Water - If the medium affected is surface water. provide the following information: 

a If the release affects any swface water body. ve the name of the water body. 

b. If the release affects a stream. give the ''stream order .. or the arerage.flow rate (in cubic feet per second). This 

iJ?formation can be obtained/rom your slate water resource division of USGS. If you cannot/ocate this 

information. use the chart below to estimate the flow rate according to the velocity of the stream. If the velocity of 

the stream fluctuates during the year. use the average velocity when calculating average flow rate. 

c. If the release affects a lake. or other large surface water body (e g . a bay) give the swface area oft he lake (in 

acre:.) and the average depth (in feet or meters). Below are sources of information for estimating the average lake 

depth. 

3. Soil or Ground Water -If the medium a.ffected is soil or [!.round water. provide the.following information: 

a. If the release is on or under ground. indicate the distance to the c:losest public water supply well within a two-mile 

radius qf the site. Information regarding the location of public: wc11er supply wells may be available through the 

county office that issues permits for wells. 

Estimated Average Stream Flow Rates 

Stream Menn Flow 

Order LCESJ 

I 0.65 

2 3. 10 

3 15.00 

4 7 1.00 

5 340.00 

6 1.600.00 

7 7.600.00 

8 56,000.00 

9 17 1,000.00 

10 81 0.000.00 

Mean 

Velocity 

(11:~ 

1.0 

1.3 

1.5 

1.8 

2.3 

2.7 

3.3 

3.9 

5.6 

5.9 

Sources of Information for Estimating Average Lake Depth 

If the lake is large enough to be navigable, y our local Coast 

Guard office will have a navigation chart that will provide the 

average depth of the lake. For smaller lakes. you may estimate 

the a1·erage depth of the lake by rely ing on your knowledge of 

the use of the lake and the surrounding area. and your best 

professional j udgment. 

QptiOIII!l jn(ommtion - 1'111: foltowmg mformalwn It UIU reqmred 10 COIIIfl~l " 11h 1h~ re~:ulolmll. ltoll'tl'tr . .r11ch mformolloll "1/t oss1st EPA 111 Holuolmg 1h~ nslc.r 

attactatl!d wult a COII/1111/0IIt release. If I he mform0/1()11 below IS no/ pro•·tdetl. cnnsen·n11w mlue.t witl be usetl 1o e•·oluole 1he rt.tks a.uocwted wuh I he conlmttOil.t 

rrh•an• 

I . If the sa11rce is a stack release to wr. pro \'Ide the: (n) ws1de dwmeler of the slack: (b) gas ex11 •·etncuy: a11d {c) gas 1emperat11re. 

2. If the releo.se ojJec1s swfoce water. fll'lll'ide I he m•erage wloc11y of 1he surface woler. 
Continuous Release Reporting Form 

SECTION H: SOURCE 

INFORMATION 

(continued) 

I Name of Source: 

Part B: Specific Information on the Source 

Form Approved OMB No 2050·0086 

Expirat1on Dntc· XX-XX-XXX X 

CR-ERNS Number: II 

For the source identified above, provide the follmving information. 

EACH source. 

Please provide a SEPARATE sheet for 

AFFECTED MEDIUM. Identify the environmental medium (i.e .. air. surface water. soil. or ground water) that is affected 

by the release from this source. If your source releases hazardous substances to more than one medium (e.g., a wastepile releasing 

to air and ground water), treat the release to EACH medium as a separate source and complete Section II, Parts A, B, and C, of this 

fo rmat for EAC II medium affected . 

0 AIR I f the medium affected is air, please also specify whether the source is a stack or a ground-based area source. 

O tacl< Indicate stack height in feet or meters 

0 SURFACE WATER 

If the release affects any surface water body, give the name of the water body. 

Surface 

D Water Body 

O Stream If the release affects a stream, give the stream order or average now rate, in cubic feet per second. 

Stream Order I OR Average Flow Rate (cubic feet/seco nd)' 

O Lake Surface area o f lake (in acres)L'--- ---' Average depth of lake (in meters)~..I _ ____ _J 

I fthe release affects a lake, give the surface area o f the lake in acres and the average depth in meters. 

0 SOIL OR GROUND WATER 

l f the release is on or under ground, the location of public water supply wells within two miles. 

I 

Optional Information _ 'l1te lollowmg inlormallon is not required to comply with the regulat1on: however, such mformauon w1ll nss1st loP A m cvaluaung the nsks 

assocaatcd wnh the conti nuous rclcnsc If I his information is not prn,•idrd. EP,\ "ill rn:1kr ronsrn•:llivr assumptions about th r appropri11tr 

valur,. Please note that the units spcc1fied hclow arc suggested llltlts You may usc other un1ts. however. be ecrlllin that the umts are clearly 

1dcnuti cd 

For n stuck rclca~c to mr. prov1dc the tollowmg mt'onnauon, 1t'avmlnble 

hlSidc diameter (feet or meters) D Gas Exu Velocity (li or meters/sec) D Gas Temp (degrees Fahrenheit, Kc lvm. or Ce lsius) D 

for 11 rclca c to surlilcc w,ucr, prov1dc the tollo,,mg mlormauon, 1favallable: 

Average velocity of surface watcr(lcetlsccond) l,... --------, 

I' A Form 6 l 00- l 0, Continuous Release Reporting Fom1 Page of 
EXAMPLES OF REPORTING SINGLE HAZARDOUS SUBSTANCES 

(Stack 

In this 

A) 

example

arc hydr

, your 

oge

facilit

n 

y has a release which may qualify for reduced reporting as a continuous release. The hazardous substances released 

chloride (7647010) and hydrogen nouride (7664393). 

once 

The volume 

per week 

of hydrogen chloride (HCI) released in 24-hour period is between 0 and 9,950 lbs. During the previoius year. 11.500 lbs of HCI wa

approximately 

in February and June for a total of 8 days per year. The amount of hydrogen nouridc (HFI) released is between I and 6,000 lbs. 

120 days each year. A total amount released last year was 13,800 lbs. 

For these releases from the specific source, you must provide the information outlined below. 

Nom1al Range Number of Days Total Quantity 

N.am_e_of (in lbs., kg or Ci per day) Release Occurs Released in Previous Year 

tiazardous Substance CASRN # .!.l.P..IW Bound Lower Bound (per year) (in lbs., kg or CD 

Hydrogen Chloride (HCI) 7647010 9,950 lbs Olbs 8 11.500 lbs. 

Hydrogen Flouride (Hfl) 7664393 6,000 lbs llb 120 13,800 

EXAMPLE OF REPORTING A MIXTURE 

include 

In this example, if your fac ility wants to report the release of a mixture of hazardous substances, you must list each component of the mixture by 

2,3,5-triitS chlorophenol: percentage by weight. For example, for the release of mixture Z. you must provide the following infonnation about itS components, e

Name of Mixture 

z 

z 

z 

z 

Name of Hazardous 

Substance 

Components 

(components listed 

below) 

Ethylene oxide 

Acrolein 

2,3,5-trichlorophenol 

CASRN # 

75218 

107028 

933788 

Weight 

Pcrcenta!!.e 

10% 

15% 

20% 

Nonnal Range of I o!lf Nomlal Range of 

Components Mixture 

(in lbs., kg or Ci per day) (in lbs., kg or Ci per day) 

Upper Lower Upper Lower 

Bound Bound Bound Bound 

100 lbs 0 lbs 

lOibs 0 lbs 

151bs 0 lbs 

20 1bs 0 lbs 

To

Number of Days M

Release Occurs in 

(per year) (in 

365 
eporting Form 

E lNFORMATION 

ed) 

Form ApprO\'Cd OMB No 2050-0086 

Exp1rauon Date XX-XX-XXXX 

I CR-ERNS Number: I 

ntity of Each Hazardous Substance or Mixture Released From Each Source 

TE sheet for EAC!I source. 

 

released from the source identified above and provide the followin g information. Include umts where appropnate Rad1onuchdes 10 cuncs (C1) 

Nonnal Range Number of Days Total Quantity 

(in lbs., kg, or Ci per day) Release Occurs Released in Previous Y car Period of the 

 CASRN il 

m~er BQund l'"ower Bound (uer vear) (in lbs., kg, or Ci) Release 

I 

I I I 

I I I 

I I I 

I I 

m the sou rce identified above and provide the following information . Include umts \\here appropriate Radionuchdcs m cunes (Ci) 

Normal Range of Ej Nom1al Range of 

Components Mixture Total Quantity of 

zardous (in Jbs., kg, or Ci per day) (in lbs., kg, or Ci per day) Number of Days Mixture Released Period of 

nce Weight Upper Lower Upper Lower Release Occurs in Previous Y car the 

le!lt:i C6SRi'\l # ers;~ntage .B.ru!rul. .8ru!!!.Q. .!12.urul. fullirui {uer :ts:l!r) (in lbs .. kg 2r Cil ~ 

I I I I I I I I I 

I I I I I I I I I 

I I I I I I I I I 

lease Reporting Fom1 ·-- -

II 

I 
INSTRUCTIONS 

SECTION II: SOURCE INFORMATION 

(Part C) 

f a C ERCLA hazardous substance(s), you will be assigned a C R-ER.. VS number when you make this initial telephone call to the NRC 

NS number II' ill become the identifier for your f acility. Your CR-ER..VS number will never change: it is the number that identifies you in the C R- 

f Each Hazardous Substance or Mixture Released: 

t information about the identity and quantity of the ha:ardous subswnces released from the source. In particular, you must identify the normal 

al annual quantity released during the previous year from each source. 

 to monitor releases. to determine the normal range of the release. l'ou may establish the normal range by using engineering estimates of releases 

ns, knowledge of the operating history of tire facility. experience with operating processes. professional j udgment, or any other method that has a 

use the upper bound of the normal range to estimate the risks to human health and the environment posed by the ha:ardous substance release. 

ion regarding the quantity of the hazardous substance released from each identified source. you should begin by determining whether the release 

or a mixlllre of hazardous substances. 

Normal Range 

s release includes all releases of a ha:ardous substance (in pounds, kilograms, or curies) reported or occurring during any l.f-hour period under 

ng the pre1·ious year Only releases that are both continuous and stable in quantity and rate may be included in the normal range. 

s - For J:ru;h source, follow the dm:ct1ons below to report each hazardous substance re leased from the source that 1s a smglc hazardous substance or a component of a mixture thm you 

e 

 c

released 

atalogue

by 

s

name and by Chemtcal Abstracts Sen ·tce Reg/Sir)' N1m1ber (CASR.\') Tl1r CASRN for a ha:ardortS substance can be located many matenal safety data sheet or m . 

unds of the normal range of the release from the 1demr[ied source (1 e. quamrty 111 po11nds. ktlograms, or cun es) durmg the prei'IOIIS year 

t (111 pounds. lulograms. or curtl!s) of the ha:ordous substance released from the 1demrjied soura durmg the pre\'IOitS year . 

ase 

ce m

by 

ay 

m

be 

drca

co

11ng tire mm1htr of dayo~tlre release occurs per y ear from the 1demi[ted source. Staung "commuous" IS not suj]ictelll, as one source may be con11nuoruly operaung 365 llltnUOitSiy operating on weekifays. 261 days a y ear. 

elease occurs 

follow the directions belo" to report each mixture released from the source 

g .. Blue Pigment 1125). 

ce component of the m1x111re by name and CASliN. 

hc of eaclr ha:ardo1tS substance componem of th<' ntt.tture 

e wo1ds f e(t ace h .. quantrry 111 pow1ds. k1lograms. or cunes) of the normal range of each lra-qrtfous substance coamonent of the m1.tture that was released from tlrrs source To calculate the 

lra:ardous bs c~ compan<'lll. m1dnpZv the ll'e1glrt percemage of each componetll by the nppa bound qua/111/y of the mtxutre. 

unds (c e., quanmy Ill paw1ds, kilograms. or curces) of the normal range of t/11• l1lill1ICt. that was releas~d from the tdemifled source durmg the pre\'IOUS y ea1· 

ase 

e m

h)

a_1

' 

· 

mdtcamcg 

be comuwo

the 

u

number of da)S the release occurs per year fi'onr the tdwtrfied source. Statmg "conttmtous " IS not suj}ictelll. as one source ma) be contmuortS~' operatmg 365 sly operatrng on ll'eekifays. 261 days a year. 

y (in pounds, ktlograms. or crm es) of the !l.l.l.I.U1!:f. that was rl'leased from tire tdemrjied source durmg the fl''l!l'ious year 

lease occurs. 
Continuous Release Reporting Form 

SECTION lll: SUBSTANCE 

INFORMATION 

Calcu lation of the SSI Trigger 

I 

Form Approved OMB No. 2050-0086 

Expiration Date XX-XX-XXXX 

CR-ERNS Number: I 

For EACH hazardous substance component of a mixture indicated in S ection II, Part C, list the names of 

the releasing sources and their upper bounds. Please use a SEPARATE sheet for EACH hazardou.<o 

substance. 

I Name of Haza rdous Substance' 

To calculate the SSI trigger (i.e., the upper bound of the normal range of a release) for the hazardous substance identified 

above, aggregate the upper bounds of the nonnal range of the identified hazardous substance across al l sources identified in 

!Section II, Part C. If the hazardous substance is also a component of a mixture, be certain to include the upper bound of the 

component as calculated in Section II, Part C, in your calcu lation of the SSI trigger. 

llwcr BQuod Q( I be ~ormal Range Qf ~muc (SQ!m ~(.s ) !h~ ~~ l!<ll :!~ (SR~~if~ lbs .. kg .. Qr Ci) 

I I 

I I 

I I 

I I 

I I 

I I 

I I 

I I 

I I 

TOTAL- SSI trigger for this hazardous substa nce release*: 

* This method for calculating the SS!triggerfor the hazardous substance assumes that all releases of the 

same hazardous substance or mixture occur simultaneously. To the extent that a hazardous substance is 

releasedfrom your.facility ji·om d(flerent sources and at d(fferentfrequencies, you may adjust the SS!trigger 

as appropriate so that it more accurately reflects the frequency and quantity o.f the release. The SS! trigger 

in the .final analysis must reflect the upper bound o.f the normal range of the release, taking into 

consideration all sources o.fthe release at the facility or vesseL. The normal range of the release includes all 

releases previously reported or occurrin~-: over a 2-1-hour period dw·ing the previous year. 

EPA Form 6100-1 0, Continuous Release Reporting Form 

Page of 

II 

II 
INSTRUCTIONS 

SECTION Ill: SUBSTANCE INFORMATION 

CR-ERNS Number: 

if you are reporting a release of a CERCLA hazardous suhstance(s). you will be assigned a CR-ERNS number when you make 

this initial telephone call to the NRC {1-800-424-8802). This CN-ERNS number will become the identifier for your facility. Your 

CR-ERNS number will never change: it is the number that identifies you in the CR-D?NS database. 

After you provide the required information/or all sources of continuous releases from your facility. you must aggregate 

information of a hazardous substance release from all sources to determine the SSt/rigger (upper bound oj1he normal range) 

for each ha::ardous substance released at your facility. 

The SSI trigger of a particular hazardous substance is calculated by aggreJ::ating the upper bounds of the hazardous 

substance released across all sources at a facility. 

if you are aggregaling ('t:;NCLA ha:ardous substance releases ji'om separate. conliguous, or adjacent facilities and 

reporting !hem in a single report. aggregate the upper bound of the normal range of the hazardous substance released from all 

sources at the site to determine the SSt trigger. if you aggregate your releases across f acilities. the SS/trigger must also be sitespecific, not facility-specific. Aggregating releases acrossfacilities at the same site may reduce your reporting burden: however, 

EPA will evaluate I he risks associaled with the releases as ((the releases were .from one.facility. 

To calculate the SSt trigger for e..m;;h. hazardous substance you should: 

Ust each specific source name and emer the upper hound of the normal range of the release from thai source. if the 

identified ha;ardous substance is a component of a mLrture, enler the upper bound of the normal range for thai 

component of the mixture (as determined in Section II, Part C). 

2. ARgre~ate the upper bound quantitiesji·om each source q(the release. Report these totals as the SSt trigger/or the 

hazardous suhslance. The example thai is provided below illustrates the calculation of the SS!Iriggerfor a release of 

ammonia. 

The above method for calculating the SSt trigger of a ha:ardou:; substance assumes that all releases of the same 

ha:ardous substance occur simultaneously (i.e .. over the same 2-1-hour period). To the extent that the .frequency oft he release 

differs, you may adjust the SSt trigger so that it more accurately reflects thefrequem.y and quantity of I he hazardous substance 

released .from all sources over a 24-hour period The .)'Sf trigger in the final analysis must reflect/he upper bound of the normal 

range of the release. taking into consideration all sources oflhe release allhefacility. The normal range of the release includes 

all continuous releases previously reported or occurring over a 24-hour period during the previous year. 

Ca lculation of the SSI Trigger fo r a 

Hazardous Substance 

llazardous Upper 

Substance Source Bound 

Ammonia Tank VentS 120 lbs. 

in Building # I 

Valves in 11 5 lbs. 

Building #5 

Upper Bound for Ammonia 235 lbs. 

For the purposes of this example, it is assumed 

that the only sources of the ammonia release at 

the fac ility arc the Tank Vents in Building #I 

and the Valves in 13uilding #5. 

Paperwork Reduction Act Notice 

The public reporting and recordkeeping burden for this collection 

of information is estimated to average I() hours per response.Send 

comments on the Agency's need for this i1!formation, the accurac.y 

<if the provided burden estimates. and any sugf!,e.wed methods for 

minimi:ing respondent burden. including through the use of 

automated collection techniques to the Director, Collection 

Stratef!,ies Division. U.S. Environmenlal Protection Agency 

(28227), 1200 Penn\y lvania Ave .. NIV, Washington, D. C. 20-160. 

Include the 0/v/B control number in any correspondence. Do !WI 

semi tlte completer/form to tltis address.