SECTION I: GENERAL

 INFORMATION CR-ERNS Number:

Date of Initial Release: Date of Initial Call to NRC:

Type of Report: Select from the drop-down list,

 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.

Date Name and Position Signature

Part A. Facility or Vessel Information

Name of Facility or Vessel

Person in Charge

of Facility or

Vessel

Facility Address

or Vessel Port of

Registration

Name Position

Phone Number Alt Phone No.

Street

City State Zip Code

County

Dun and Bradstreet Number for Facility

Facility/Vessel

Location

Latitude

Longitude

Deg

Deg Min Sec

Min Sec Vessel LORAN Coordinates

NOTE: Latitude/Longitude information can be obtained at the following websites: http://www.satsig.net/maps/lat-long-finder.htm, http://earth.google.com/,

and http://www.census.gov/geo/landview/. Do not use P.O. Box, Rural Route or Mailing Address. Use physical location only.

Part B. Population Information

Sensitive

Populations and

Ecosystems within

One-Mile Radius

Population

Density

Select from the drop-down list, the range that

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

Sensitive Populations or Ecosystems

(e.g., elementary schools, hospitals, retirement communities,

or wetlands)

Estimated Distance and Direction from

Facility, if Known

Continuous Release Reporting Form Form Approved OMB No. 2050-0086

Expiration Date: XX-XX-XXXX

EPA Form 6100-10, Continuous Release Reporting Form Page 1 of
INSTRUCTIONS

SECTION I: GENERAL INFORMATION

CR-ERNS Number:

 If you are reporting a release of a CERCLA hazardous substance(s), you will be assigned a CR-ERNS number when you make this initial telephone call to the NRC

(1-800-424-8802). This CR-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-ERNS database.

Type of Report - Select from drop-down list.

Initial Written Notification - Within 30 days of the initial telephone notification,

you are required to submit an initial written report to the appropriate EPA

Regional Office, SERC, and LEPC (for releases of CERCLA hazardous

substances) and to only the appropriate SERC and LEPC (for releases of nonCERCLA EHSs). The purpose of this report is to confirm your intent to report

your release as a continuous release under Section 103(f)(2), and to provide

government response officials with sufficient information about your release to

enable them to determine if the release qualifies as a continuous release.

First Anniversary Follow-up Report - For reports of releases of CERCLA

hazardous substances, within 30 days of the first anniversary of your initial written

report, you are required to reassess your initial continuous release report and

gather the information on all of the reported substances being released. After

doing this, you must submit a one-time written first anniversary follow-up report to

the appropriate EPA Regional Office. Please note that the first anniversary report

must be sent to the appropriate EPA Regional Office for all reports of CERCLA

hazardous substances, but is not required for reports of non-CERCLA EHSs.

Written Notification of a Change to Initial Notification and/or Written Notification of a Change to Follow-up Report -

[NOTE: For these reports, select the report type that reflects the notification or report for which you are reporting a change.]

= Notification of a change in source or composition, which is treated as if it were a new release (i.e., with a telephone call to the NRC, SERC, and LEPC, followed by

 a written report and a first anniversary follow-up report);

= Notification of a change in the normal range, if there is a change in the release such that the quantity of the release exceeds the upper bound of the reported normal

 range, the release must be reported as a statistcally significant increase;

= For CERCLA substances only, notification of any other reported information (e.g., a change in facility ownership) in a written letter to only the EPA Region.

Part A. Facility or Vessel Information -

 1. The complete name of your facility (and company identifier where appropriate). If multiple facilities are included in your written report, provide the plant site

 name with the name of the facility.

2. The full address of your facility, including the street address or highway marker, city, county, state, and zip code. A post office box number should not be used

 as the facility address. The address provided should be the location of the facility where the hazardous substance release occurs.

3. The location of your facility by its latitude and longitude in units of degrees, minutes, and seconds. See below for helpful hints on how to obtain the latitude

 and longitude coordinates of your facility.

4. The nine digit number assigned by Dun and Bradstreet (D&B) to your facility. This number can be obtained via telephone by an officer of your company

 from the national office of Dun and Bradstreet (at 1-800-234-3867). If your facility has not been assigned a D&B number, please specify that the information

 is not applicable. http://www.dnb.com/US/duns_update/

5. For reports of CERCLA hazardous substances, the CR-ERNS number assigned by the NRC when you made the initial telephone report. Be certain to include

 the CR-ERNS number on each page of your report.

6. The name, telephone number (including area code), and an alternate telephone number for the person in charge of your facility.

Part B. Population Information -

 1. Choose the range from the drop down list, the range that most accurately describes the population density within a one-mile radius of your facility.

2. Identify and describe the location of any sensitive populations or ecosystems within a one-mile radius of your facility. If possible, describe the location of the

 populations or ecosystems in terms of distance and direction from your facility (e.g., located 1⁄4 mile northwest of the facility). Exact addresses are not

 required.

The information required in Section I of the initial written report and follow-up reports includes general information identifying your facility, as well as information

regarding the area in which your facility is located. This general information is important because it provides a better understanding of the potential risks resulting

from exposure from the facility's release. A signed statement asserting that the continuous release is continuous and stable in quantity and rate, and that the

information supplied is accurate and current to the best of your knowledge, is also required in Section I.

In addition, Section I must clearly identify the type of written report that you are submitting (i.e., an initial written report, a first anniversary follow-up report, or a

written report of the change in source or composition of a previously reported release). You must also include information on the initial notification of the release,

such as the date of the release and the date of the initial call. For CERCLA hazardous substances, the CR-ERNS number assigned to you by the NRC will also be

required.

SOURCES OF INFORMATION FOR IDENTIFYING THE LOCATION OF YOUR FACILITY

Sources of data on latitude and longitude coordinates of your facility include EPA permits (e.g., NPDES permits), county property records, facility blueprints, and site

plans. In addition, information on the latitude and longitude of your facility may be obtained from a United States Geological Survey (USGS) topographical map.

These maps are available in both the 7.5 minute and 15 minute series. These maps may be obtained from the USGS distribution center at your local public library. If

you would like to order a map from USGS, contact: U.S.Geological Survey - Information Services, Box 25286, Denver, CO 80225, call 1-888-ASK-USGS

(1-888-275-8747)/http://library.usgs.gov/maplinks.html

 If you are not certain on which map your site is located, consult the index of topographic maps for your state, which may be obtained from USGS free of charge.

USGS maps are also available at commercial dealers such as surveyors or outdoor recreation equipment dealers.

Latitude/Longitude information can be obtained at the following websites: http://www.satsig.net/maps/lat-long-finder.htm, http://earth.google.com/, and http://www.

census.gov/geo/landview/.

Sensitive populations - populations likely to be more susceptible than average individuals to the effects of exposure to a hazardous substance. Examples of sensitive

populations are elementary school children, retirement communities, or hospitals.

Sensitive ecosystems - environments likely to be more susceptible than average environments to the effects of exposure to a hazardous substance, or ecosystems that

have been designated for special protection by Federal or state governments. Example of sensitive ecosystems includes wetlands.