New Submission

Your Information

Type of Party Reportingfield type drop-down
Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Company Namefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Email*field type email
Contact Phone*field type single line
XXX-XXX-XXXX
Input blocked. Maximum character limit of 4000 characters reached.
Alternate Phonefield type single line
XXX-XXX-XXXX
Input blocked. Maximum character limit of 4000 characters reached.
Mailing Addressfield type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country

Location*field type multi line
(Street address, nearest intersections, or latitude/longitude)
City*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
County of Incidentfield type drop-down
Sectionfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Township (N/S)field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Range (E/W)field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Directions to Incident Locationfield type multi line
Pipeline Company Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Operator Typefield type drop-down

Event Description*field type multi line
Input blocked. Maximum character limit of 1000 characters reached.
Date of Event*field type date
MM/DD/YYYY
Event Time*field type time
(CST) For exact time, please manually enter using H:MM format (example 1:30)
Confirmed Discovery Date*field type date
MM/DD/YYYY
Confirmed Discovery Time*field type time
(CST) For exact time, please manually enter using H:MM format (example 1:30)
Material Type Dischargedfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Estimate Volume (bbls)field type number
Estimate Volume (Mcf)field type number
Estimated Property Damagefield type currency
$
Injuries (quantity)*field type number
Fatalities (quantity)*field type number
Facility Typefield type drop-down
Accident/ Incident Typefield type drop-down

Excavator Namefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Excavator Addressfield type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Excavator Contact Numberfield type single line
XXX-XXX-XXXX
Input blocked. Maximum character limit of 4000 characters reached.
Excavator Equipment*field type drop-down

NRC Report Numberfield type number
NRC Report Datefield type date
MM/DD/YYYY
NRC Report Timefield type time
(CST) For exact time, please manually enter using H:MM format (example 1:30)
Commentsfield type multi line
Input blocked. Maximum character limit of 1000 characters reached.