DEP Form 62-761.900(1) "Discharge Report Form" - Florida

What Is DEP Form 62-761.900(1)?

This is a legal form that was released by the Florida Department of Environmental Protection - a government authority operating within Florida. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the Florida Department of Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DEP Form 62-761.900(1) by clicking the link below or browse more documents and templates provided by the Florida Department of Environmental Protection.

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Download DEP Form 62-761.900(1) "Discharge Report Form" - Florida

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Department of
DEP Form: 62-761.900(1)
Form Title: Discharge Report Form
Environmental Protection
Effective Date: January 2017
Incorporated in Rule 62-761.405, F.A.C.
2600 Blair Stone Road ♦ Tallahassee, Florida 32399-2400
DISCHARGE REPORT FORM
Complete all applicable blanks, and submit copies of any analytical or field test results confirming contamination to soils, surface water, or groundwater to the County
via email or mail.
Facility ID Number (If Registered):
Date of Form Completion:
Date of Discovery: __________________
Facility Name:
County:
Facility (Property) Owner:
Telephone Number:
Owner Mailing Address:
Location of Discharge (Facility Street Address):
Lat/Long:
Date of receipt of any test or analytical results confirming a discharge:
Estimated number of gallons discharged:
Discharge affected: (Check all that apply)
Soil
Groundwater
Soil water (water body name)
Drinking water well(s)
Shoreline
Other (specify)
Evidence of discharge: (Check all that apply)
Visual observation of sheen
Results or receipt of results of analytical tests
Stained soils
Visual observation of free product
Spill or vehicle overfill > 25 gallons to a pervious surface
Other (explain in comments)
Method of discovery and confirmation of discharge: (Check all that apply, see rule language explanation on instructions for this form)
Visual observation
Closure/Closure sampling assessment
Surface water analytical results
Groundwater analytical results
Soil analytical results
Other (specify)
Type of regulated substance discharged: (Check all that apply)
Gasoline
Jet fuel
Mineral acids (ASTs)
Diesel
Used/waste oil
Ammonia compound
Chlorine compound
Heating oil
New motor/lube oil
Biofuel blends
Kerosene
Pesticide
Unknown
Aviation gas
Grade 5 & 6 residual oils
Other (specify)
Hazardous substance (USTs) – write name or Chemical Abstract Service (CAS) #:
Discharge originated from a: (Check all that apply)
Tank
Other secondary containment
Railroad tankcar
Piping
Fitting or pipe connection
Barge, tanker ship or other vessel
Spill bucket
Valve
Pipeline
Dispenser
Tank truck
Drum
Piping sump
Vehicle or customer vehicle
Unknown
Dispenser sump
Aircraft
Other (specify)
Cause of the discharge: (Check all that apply)
Spill
Material failure (crack, split, etc.)
Collision
Weather
Overfill
Material incompatibility
Vehicle accident
Human error
Corrosion
Improper installation
Fire/explosion
Unknown
Puncture
Loose connection
Vandalism
Other (specify)
Actions taken in response to the discharge:
Comments:
Agencies notified (as applicable):
Fire Department
County Program
District Office
State Watch Office
National Response Center
800-320-0519
800-424-8802
To the best of my knowledge and belief, all information submitted on this form is true, accurate and complete.
Printed Name of Owner, Operator or Authorized Representative
Signature of Owner, Operator or Authorized Representative
Department of
DEP Form: 62-761.900(1)
Form Title: Discharge Report Form
Environmental Protection
Effective Date: January 2017
Incorporated in Rule 62-761.405, F.A.C.
2600 Blair Stone Road ♦ Tallahassee, Florida 32399-2400
DISCHARGE REPORT FORM
Complete all applicable blanks, and submit copies of any analytical or field test results confirming contamination to soils, surface water, or groundwater to the County
via email or mail.
Facility ID Number (If Registered):
Date of Form Completion:
Date of Discovery: __________________
Facility Name:
County:
Facility (Property) Owner:
Telephone Number:
Owner Mailing Address:
Location of Discharge (Facility Street Address):
Lat/Long:
Date of receipt of any test or analytical results confirming a discharge:
Estimated number of gallons discharged:
Discharge affected: (Check all that apply)
Soil
Groundwater
Soil water (water body name)
Drinking water well(s)
Shoreline
Other (specify)
Evidence of discharge: (Check all that apply)
Visual observation of sheen
Results or receipt of results of analytical tests
Stained soils
Visual observation of free product
Spill or vehicle overfill > 25 gallons to a pervious surface
Other (explain in comments)
Method of discovery and confirmation of discharge: (Check all that apply, see rule language explanation on instructions for this form)
Visual observation
Closure/Closure sampling assessment
Surface water analytical results
Groundwater analytical results
Soil analytical results
Other (specify)
Type of regulated substance discharged: (Check all that apply)
Gasoline
Jet fuel
Mineral acids (ASTs)
Diesel
Used/waste oil
Ammonia compound
Chlorine compound
Heating oil
New motor/lube oil
Biofuel blends
Kerosene
Pesticide
Unknown
Aviation gas
Grade 5 & 6 residual oils
Other (specify)
Hazardous substance (USTs) – write name or Chemical Abstract Service (CAS) #:
Discharge originated from a: (Check all that apply)
Tank
Other secondary containment
Railroad tankcar
Piping
Fitting or pipe connection
Barge, tanker ship or other vessel
Spill bucket
Valve
Pipeline
Dispenser
Tank truck
Drum
Piping sump
Vehicle or customer vehicle
Unknown
Dispenser sump
Aircraft
Other (specify)
Cause of the discharge: (Check all that apply)
Spill
Material failure (crack, split, etc.)
Collision
Weather
Overfill
Material incompatibility
Vehicle accident
Human error
Corrosion
Improper installation
Fire/explosion
Unknown
Puncture
Loose connection
Vandalism
Other (specify)
Actions taken in response to the discharge:
Comments:
Agencies notified (as applicable):
Fire Department
County Program
District Office
State Watch Office
National Response Center
800-320-0519
800-424-8802
To the best of my knowledge and belief, all information submitted on this form is true, accurate and complete.
Printed Name of Owner, Operator or Authorized Representative
Signature of Owner, Operator or Authorized Representative