guide for preparing · · 2007-10-19(1) is listed in appendix a to § 172.101; (2) is in a...

Guide for PreparingHazardous MaterialsIncidents Reports

Revised January 2004Supersedes Previous Edition

U.S. Departmentof Transportation

Pipeline andHazardous MaterialsSafety Administration



Hazardous MaterialsIncident ReportingCONTENTSOverviewWhat Federal Regulation requires me to submit the Report? ............ 1What is the purpose of the Report? ................................................... 1Who must complete the Report? ....................................................... 1What definitions should I know in order to complete the Report? ...... 1When must I submit a Written Report (DOT Form F 5800.1)? .......... 2When is a Report not required? ......................................................... 3When must I make a Telephonic Report? .......................................... 3What telephone number do I call to make an Immediate

Notification of a Hazardous Materials Incident?.............................. 3How long do I have to submit the Written Report? ............................ 4Am I required to update the information in the Report? ..................... 4How and where do I submit my completed Report? ........................... 4How long must I keep a copy of the Report? ..................................... 4Where must I keep a copy of the Report? ......................................... 4How can I get a blank copy of the DOT Form F 5800.1? ................... 4How long does it take to complete the Report? .................................. 4How can I comment on the length of time needed to

complete the Report or on the amount of informationrequired in the Report? ................................................................... 4

Instructions: Completing DOT Form F 5800.1Part I: Report Type ............................................................................. 5Part II: General Incident Information .................................................. 5Part III: Packaging Information .......................................................... 6Part IV: Consequences ....................................................................... 7Part V: Air Incident Information .......................................................... 8Part VI: Description of Events and Packaging Failure ....................... 8Part VII: Recommendations/Actions Taken to Prevent

Future Incidents .............................................................................. 8Part VIII: Contact Information ............................................................ 8Failure Codes. ............................................................................... 9Incident Reporting Requirements (Effective January, 2005)Section 171.15 Immediate Notice of Certain Hazardous

Materials Incidents. ......................................................................... 11Section 171.16 Detailed Hazardous Materials Incident Reports ....... 11Hazardous Materials Incident Report Form:

DOT Form F 5800.1 (01-2004) ....................................................... 13

ii • Incident Reporting Guidelines

PHH50-0044-1104

What Federal Regulation RequiresMe To Submit the Report?The Hazardous Materials Regulations(HMR; 49 CFR Parts 171-180) requirecertain types of incidents be reported tothe Pipeline and Hazardous MaterialsSafety Administration (PHMSA). Section171.15 of the HMR requires an immediatetelephonic report (within 12 hours) ofcertain types of hazardous materialsincidents. Section 171.16 requires awritten report for cer tain types ofhazardous materials incidents within 30days of the incident, and a follow-upwritten report within one year of theincident, based on certain circumstances.Each type of report is explained below.(The full text of these sections is at the endof the instructions.)

What is the Purpose of the Report?The information you are providing in thisreport is fundamental to hazardousmaterial transportation risk analysis andrisk management by government andindustry. It allows us to better understandthe causes and consequences ofhazardous material transportationincidents. The data is used to identify trendsand provide basic program performancemeasures. It helps to demonstrate theeffectiveness of existing regulations andto identify areas where changes should beconsidered. It also assists all parties,including industry segments and individualcompanies, to understand the types andfrequencies of incidents, what can gowrong, and possible measures that wouldprevent their recurrence. Your accurate andcomplete description of incidents can makea significant contribution to continual safetyimprovement through better regulations,cooperative partnerships, and individualefforts.

Who Must Complete the Report?Any person in possession of a hazardousmaterial during transportation, includingloading, unloading and storage incidentalto transportation, must report to theDepartment of Transportation (DOT) ifcertain conditions are met. This means thatwhen the conditions apply for completingthe report, the entity having physicalcontrol of the shipment is responsible forfilling out and filing DOT Form F 5800.1.

Generally, the entity having physicalcontrol of the shipment duringtransportation will be the carrier. Forincidents that occur when a hazardousmaterial is stored temporarily duringtransportation, the entity in physicalpossession of the shipment may be awarehouse or similar storage facility.

Loading operations. Incidents that occurwhile a shipper is loading a hazardousmaterial onto a transport vehicle or into abulk packaging, such as a cargo tank,portable tank, or rail tank car, before thecarrier arrives at the facility to pick up theshipment are not required to be reportedbecause these incidents occur prior to theonset of transportation in commerce.Incidents that occur while the carrier thatwill be transporting the hazardousmaterial is observing or participating inloading operations must be reportedbecause the carrier is deemed to be inpossession of the hazardous material atthat point; thus, these incidents occurduring transportation. For these incidents,the carrier must complete the report.

Unloading operations. Incidents that occuror are discovered while a consignee isunloading a hazardous material from atransport vehicle or bulk packaging afterthe carrier has delivered the material arenot required to be reported because theseincidents occur after transportation hasended. Incidents that occur while thecarrier that delivered the hazardousmaterial is observing or participating inunloading operations must be reportedbecause the carrier is deemed to be inpossession of the hazardous material atthat point; thus, these incidents occurduring transportation. For these incidents,the carrier must complete the report.

What Definitions Should I Know inOrder to Complete the Report?In order to accurately complete the report,you should be familiar with the followingterms. A complete list of definitions iscontained in § 171.8.

Bulk packaging—a packaging, other thana vessel or a barge, including a transportvehicle or freight container, in which haz-ardous materials are loaded with no in-

termediate form of containment and thathas:

(1) A maximum capacity greaterthan 450 liters (119 gallons) as areceptacle for a liquid;

(2) A maximum net mass greater than400 kilograms (822 pounds) anda maximum capacity greater than450 liters (119 gallons) as areceptacle for a solid; or

(3) A water capacity greater than454 kilograms (1,000 pounds) asa receptacle for a gas as definedin § 173.115.

Cargo tank—a bulk packaging that is:(1) A tank intended primarily for the

carriage of liquids or gases andincludes appurtenances, reinforce-ments, fittings, and closures;

(2) Permanently attached to or formsa part of a motor vehicle, or isnot permanently attached to amotor vehicle but which, byreason of its size, construction, orattachment to a motor vehicle, isloaded or unloaded withoutbeing removed from the motorvehicle; and

(3) Not fabricated under a specifica-tion for cylinders, intermediatebulk containers, multi-unit tank cartanks, portable tanks, or tankcars.

Hazardous material—a substance or ma-terial that has been determined to be ca-pable of posing an unreasonable risk tohealth, safety, and property when trans-ported in commerce, and that has beenso designated. The term includes hazard-ous substances, hazardous wastes, marinepollutants, elevated temperature materials,materials designated as hazardous underthe provisions of § 172.101, the Hazard-ous Materials Table (HMT), and materialsthat meet the defining criteria for hazardclasses and divisions in Part 173.

Hazardous substance—a material, includ-ing its mixtures and solutions, that—

(1) Is listed in Appendix A to§ 172.101;

(2) Is in a quantity, in one package,which equals or exceeds the re-portable quantity (RQ) listed in Ap-pendix A to § 172.101; and

OverviewHazardous Materials Incident ReportDepartment of Transportation Form F 5800.1

OVERVIEW • 1

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§ 171.4) and, when in a solution or mix-ture of one or more marine pollutants, ispackaged in a concentration that equalsor exceeds:

(1) Ten percent by weight of the solu-tion or mixture for materials listedin Appendix B; or

(2) One percent by weight of the so-lution or mixture for materials thatare identified as severe marinepollutants in Appendix B.

Movement—the physical transfer of ahazardous material from one geographiclocation to another by rail car, aircraft,motor vehicle, or vessel.

Storage incidental to movement— storageof a transport vehicle, freight container,or package containing a hazardousmaterial by any person between the timethat a carrier takes physical possession ofthe hazardous material for the purpose oftransporting it until the package containingthe hazardous material is physicallydelivered to its destination.

Transloading—the transfer of a hazardousmaterial from one bulk packaging toanother bulk packaging, from a bulkpackaging to a non-bulk packaging, orfrom a non-bulk packaging to a bulkpackaging for the purpose of continuingthe movement of the hazardous materialin commerce.

Transportation—the movement of propertyand loading, unloading, or storageincidental to that movement.

Undeclared hazardous material—ahazardous material that is:

(1) Subject to any of the hazard com-munication requirements in sub-parts C (Shipping Papers), D(Marking), E (Labeling), and F(Placarding) of Part 172 of thissubchapter, or an alternativemarking requirement in Part 173of this subchapter (such as§§ 173.4(a)(10) and 173.6(c));and

(2) Offered for transportation in com-merce without any visible indica-tion to the person accepting thehazardous material for transpor-tation that a hazardous materialis present, on either an accom-panying shipping document, orthe outside of a transport vehicle,freight container, or package.

(3) When in a mixture or solution—(i) For radionuclides, conforms

to paragraph 7 of AppendixA to § 172.101.

(ii) For other than radionclides, isin a concentration by weightwhich equals or exceeds theconcentration correspondingto the RQ of the material, asshown in Table 1.

The term hazardous substance does notinclude petroleum, including crude oil orany fraction thereof which is not otherwisespecifically listed or designated as ahazardous substance in Appendix A to§ 172.101, and the term does not includenatural gas, natural gas liquids, liquefiednatural gas, or synthetic gas useable forfuel (or mixtures of natural gas and suchsynthetic gas).

Hazardous waste—any material that issubject to the Hazardous Waste ManifestRequirements of the U.S. EnvironmentalProtection Agency specified in 40 CFR Part262.

Loading incidental to movement —load-ing by carrier personnel or in the pres-ence of carrier personnel of packaged orcontainerized hazardous material onto atransport vehicle, aircraft, or vessel for thepurpose of transporting it, including theloading, blocking, and bracing of a haz-ardous materials package in a freight con-tainer or transport vehicle, and segregat-ing a hazardous material in a freight con-tainer or transport vehicle from incompat-ible cargo. For a bulk packaging, load-ing incidental to movement means fillingthe packaging with a hazardous materialfor the purpose of transporting it. Load-ing incidental to movement includestransloading.

Marine pollutant—a material that is listedin Appendix B to § 172.101 (also see

Unintentional release—the escape of ahazardous material from a package on anoccasion not anticipated or planned. Thisincludes releases resulting from collision,package failures, human error, criminalactivity, negligence, improper packing, orunusual conditions such as the operation ofpressure relief devices as a result of over-pressurization, overfill, or fire exposure. Itdoes not include releases, such as ventingof packages, where allowed, and theoperational discharge of contents frompackages.

Unloading incidental to movement—removing a packaged or containerizedhazardous material from a transportvehicle, aircraft, or vessel, or, for a bulkpackaging, emptying a hazardous materialfrom the bulk packaging after thehazardous material has been delivered tothe consignee when performed by carrierpersonnel or in the presence of carrierpersonnel.

Additionally, for purposes of reporting onthis form, the following definitions apply:

Lading retention system—a lading retentionsystem consists of those items or equipmentthat provide containment of hazardousmaterials at some point during transporta-tion, including loading and unloading. Thecargo tank shell, associated piping, andvalves are an example of a lading reten-tion system. Dents or damage to a tankrequiring repair to an accident protectionsystem guarding the tank are examples ofincidents that must be reported. Paint chipsand scratches to either the tank or the acci-dent protection system are examples of in-cidents that do not require reporting.

Major transportation artery—a highway,main road or secondary road but not aside street or dirt road. In the case of rail,any rail line except a rail spur.

When Must I Submit a WrittenReport (DOT Form F 5800.1)?Under § 171.16, you must submit a writtenreport within 30 days after any of thefollowing:

• An incident that was reported bytelephonic notice under§ 171.15;

• An unintentional release (seedefinit ions) of a hazardousmaterial during transportationincluding loading, unloading andtemporary storage related totransportation;

• A hazardous waste is released;

Table 1 Reportable Quantities.

2 • OVERVEIW

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Table 2 Examples to Clarify When to Report Structural Damage to a Specification Cargo Tank.

OVERVIEW • 3

• An undeclared shipment with norelease is discovered; or

• A specification cargo tank 1,000gallons or greater containing anyhazardous materials that—

(1) Received structural damageto the lading retention systemor damage that requiresrepair to a system intendedto protect the lading retentionsystem, and

(2) Did not have a release.To clarify the requirement for a reportbased on structural damage to aspecification cargo tank, Table 2 illustratessome examples.

When Is a Report Not Required?You are not required to report a releaseof a hazardous material if ALL of thefollowing apply:

• The shipment is not being offeredfor transportation or beingtransported by air;

• None of the cri teria in§ 171.15(a) applies;

• The material is not a hazardouswaste;

• The material is properly classedas an ORM-D, or a PackingGroup III material in Class orDivision 3, 4, 5, 6.1, 8, or 9;

• Each package has a capacity ofless than 20 liters (5.2 gallons)for liquids or less than 30 kg (66pounds) for solids;

• The total aggregate release isless than 20 liters (5.2 gallons)for liquids or less than 30 kg (66pounds) for solids;

• The material does not meet thedefinition of an undeclaredhazardous material in § 171.8;and

• The shipment is an undeclaredmaterial discovered in an airpassenger’s checked or carry-onbaggage during the airpor tscreening process.

Also, you are not required to reportreleases of minimal amounts of material(i.e., a pint or less) released from themanual operation of seals of pumps,compressors, or valves, during theconnecting or disconnecting of loadingand unloading lines, or, for materials forwhich venting is authorized, from vents,provided these releases do not result inproperty damage or trigger any of thetelephonic notifications requirementsfound in § 171.15.

When Must I Make a TelephonicReport?Under § 171.15, you must providetelephone notice within 12 hoursafter the incident occurs when one of thefollowing conditions occurs during thecourse of transportation and is a directresult of the hazardous material:

• A person is killed;• A person receives an injury

requiring admittance to ahospital;

• The general public is evacuatedfor one hour or more;

• One or more majortransportation arteries or facilitiesare closed for one hour or more;

• The operational flight plan orroutine of an aircraft is altered;

• Fire, breakage, spillage orsuspected radioactivecontamination occurs involving aradioactive material;

• Fire, breakage, spillage orsuspected contamination occursinvolving an infectious substanceother than a diagnostic specimenor regulated medical waste;

• There is a release of a marinepollutant in a quantity exceeding450 liters (119) gallons forliquids or 400 kilograms (882pounds) for solids; or

• A situation exists of such a naturethat in the judgment of the personin possession of the hazardousmaterial, it should be reported toDOT’s National Response Center(NRC) even though it does notmeet the above criteria.

You may decide that the situation shouldbe reported even though it does not meetany of the above criteria. Make sure thatyou request the NRC report number whenyou make your telephonic report.

What Telephone Number Do ICall to Make an ImmediateNotification of a HazardousMaterials Incident?You must call 800-424-8802 (toll-free) or202-267-2675 (toll call) to make atelephonic incident report. This is thenumber to the NRC.

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This call must be made within 12 hours ofthe events that trigger this requirement.If the incident involves an infectioussubstance, you may notify the Director,Center for Disease Control and Prevention(CDC), U.S. Public Health Service,Atlanta, Georgia, toll free at 800-232-0124. If a discrepancy of a shipmentintended for air is discovered followingits acceptance aboard aircraft, notify thenearest Federal Aviation AdministrationCivil Aviation Security Office as soon aspractical.

How Long Do I Have to Submitthe Written Report?You must submit your written report within30 days of discovery of the incident,30 days of discovery of the incident,30 days of discovery of the incident,30 days of discovery of the incident,30 days of discovery of the incident,§ 171.16(a).

Am I Required to Update theInformation in the Report?Yes. You must use DOT Form F 5800.1and check the “A supplemental (follow-up)report” box on question #2 to provideadditional information after the initial re-port. You are required to provide updatesfor up to one year after the initial filing ifmore information is gained or new devel-opments arise concerning the following,for example:

• A death results from injuriescaused by a hazardous material;

• The person responsible for pre-paring the original report learnsthat there is a misidentificationof hazardous material or pack-age information;

• Damage or loss or related coststhat were not known at the timethe report was filed becomeknown; or

• Revised estimates of damages,losses, and related costs result ina change of $25,000 or more,or 10% of the original cost esti-mates, whichever is greater, evenif the original estimate was un-der $500.

How and Where Do I Submit MyCompleted Report?

• You can mail paper copies of thereport to the Information SystemsManager, U.S. Department ofTransportation, Pipeline andHazardous Materials SafetyAdministration, Office ofHazardous Materials Safety,PHH-63, Washington, DC20590-0001; or

• You can submit the report on-lineat http://hazmat.dot.gov.

How Long Must I Keep a Copy ofthe Report?You must keep a copy of each report oran electronic image of the report for twoyears after the date you submit it toPHMSA (§ 171.16(b)(3)).

Where Must I Keep a Copy of theReport?The report must be accessible through yourcompany’s principal place(s) of business.You must be able to make the report avail-able upon request to authorized represen-tatives or a special agent of the Depart-ment within 24 hours of such a request(§ 171.16(b)(3)).

How Can I Get a Blank Copy ofthe DOT Form F 5800.1?There are a variety of sources for obtain-ing the DOT Form F 5800.1. Please notethat you are allowed to make unlimitedphotocopies of the form and distributethem.

• You may obtain limited copies ofthe form from the InformationSystems Manager at the aboveaddress.

• You may download a copy of theform from our website athttp://hazmat.dot.gov/spills.htm

• Our Fax on Demand service hascopies of the instructions and theform. Call 800-467-4922 andchoose the Fax on Demand op-tion #2.

How Long Does It Take ToComplete the Report?PHMSA anticipates that it will take youapproximately 1.6 hours to complete thisreport. This estimate includes the time itwill take you to review the instructions,search your existing data sources for in-formation, gather the required data, andcomplete and review the report.

How Can I Comment on theLength of Time Needed toComplete the Report or on theAmount of Information Requiredin the Report?You can send your comments on thereport, and any suggestions you have forreducing the amount of time needed tocomplete the report, to the followingaddress:

(1) Information Systems Manager,U.S. Department ofTransportation, Pipeline andHazardous Materials SafetyAdministration, Office ofHazardous Materials Safety,PHH-63, Washington, DC20590-0001.

Please verify that your information isaccurate. Although the requiredinformation is generally available at thetime of the incident, you may need to dosome additional investigation in order toobtain all of the facts pertaining to deaths,injuries or damage amounts. If you submitcomplete and accurate information at thetime you file the report, it will decreasethe chance of your having to supplymissing information to DOT at a later date.PHMSA may follow up on incompleteforms.

4 • INSTRUCTIONS

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(7) Location of Incident: Enter the geo-graphic location of the incident(city, county, state, and zip code).If you do not know the actual loca-tion where the incident occurred,give the location where it was dis-covered. If the incident occurredat an airport or rail yard, includethe name of the facility. If the inci-dent occurred on a body of water,include the name and/or river mile.If you do not know the street ad-dress, or if the incident occurredon a highway, include a descrip-tion such as “On I-70, mile marker240.”

(8) Mode of Transportation: En te rthe code that corresponds to themode of transportation in which theincident occurred or was discov-ered. If the incident occurred orwas discovered in an in-transit stor-age area (e.g., a terminal or ware-house), check the box that corre-sponds to the mode by which thepackage was last transported.

(9) Transportation Phase: Enter thecode that describes where the in-cident occurred in the transporta-tion system. In transit meansthe incident occurred or was firstdiscovered while the package wasin the process of being transported.In-transit storage is storage inci-dental to transportation, such as ata terminal waiting for the next legof transportation.

(10) Carrier/Reporter: Provide thename, street address, Federal DOTnumber (if applicable), and hazmatregistration number of the carrieror the entity who is reporting theincident (if other than a carrier). Theentity in physical possession of thematerial when the incident oc-curred or was discovered must re-port the incident.

(11) Shipper/Offeror: Enter the informa-tion about the person or entity thatoriginally offered for transportationthe material or package involvedin the incident.

(12) Origin: Enter the origin of the ship-ment if the address is different thanthe shipper/offeror informationentered in item #11.

(13) Destination: Enter the final destina-tion of the shipment involved in theincident.

(14) through (19):

Hazardous Material Description:Enter the proper shipping name,technical or trade name, hazardclass or division, ID number,packing group, and amount ofmaterial released. All of thisinformation, except the amount ofmaterial released, can be found onthe shipping papers thataccompany the shipment,§ 172.202. When indicating theamount of material released,include units of measurements(e.g.: 115 gallons, 69 tons).

(20) Was the material shipped as ahazardous waste? Check the “Yes”box if the material meets the defi-nition of a hazardous waste in §171.8 (requires an EPA UniformHazardous Waste Manifest). In-clude the EPA Manifest number.

(21) Is this a Toxic by Inhalation (TIH)material? If the material involvedin the incident meets the definitionof a Toxic by inhalation material in§ 173.132, check the "Yes" boxand enter the Hazard Zone in thespace provided.

(22) Was the material shipped under anExemption, Approval, or Compe-tent Authority Certificate? If theshipment was shipped under an ex-emption, an approval, or a Com-petent Authority Certificate, checkthe “Yes” box and provide the ap-propriate assigned number.

(23) Was this an undeclared hazardousmaterials shipment? If this materialwas not indicated in any way tobe a hazardous material eventhough it was required to be de-scribed as such on a shipping pa-per, or if the material would nor-mally be excepted from the ship-ping paper requirements (such asa small quantity material) and doesnot have the required markings, itis considered an undeclared haz-ardous material shipment. Checkthe appropriate box.

INSTRUCTIONS • 5

InstructionsCompleting DOT Form F 5800.1Please print. Fill in all applicable blanksaccurately to the best of your ability.

Part I: Report Type(1) This is to report: Check the box that

describes why you are filling out thisform. This will normally be “A) Ahazardous material incident.” If youare reporting an undeclaredshipment with no release, check thecorresponding box, “B).” If you arereporting an incident involving acargo tank motor vehicle containinga hazardous material that receivedstructural damage to the ladingretention system that may affect itsability to retain lading but does notrelease a hazardous material, checkthat appropriate box, “C).”

(2) Indicate what type of report this is:If this is an initial report, check the“initial report” box. If this is afollow-up to a previous report, checkthe “A supplemental (follow-up)report” box. If you are usingadditional pages, check the“Additional Pages” box.

Part II: General IncidentInformation(3), (4) Date & Time of Incident: Enter the

date and time the incident occurred.If you do not know the actual dateand time, give the date and timeyou discovered the incident. Use24-hour time for the incident time(e.g., “2400” for midnight, “1200”for noon, “0747” for 7:47 a.m.,“2115” for 9:15 p.m.).

(5) Enter National Response CenterReport Number: If this incident wasreported to the NRC, fill in thereport number NRC assigned to theincident.

(6) If you submitted a report to anotherFederal DOT agency, enter theagency and report number: If youwere required to fill out a report foranother federal agency such as theFederal Railroad Administration(FRA) or the Federal Motor CarrierSafety Administration (FMCSA) forthis incident, please include theagency and report number. This willfacil i tate our combination ofinformation.

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Part III: Packaging Information

(24) Packaging Type: Check the box thatcorresponds to the type of packag-ing involved in the incident. If morethan one packaging type was in-volved in an incident, reproducePart III of the form and fill out thissection for each of the packagingtypes. For example, if three differ-ent packaging types were involvedin an incident, fill out a separatePart III for each packaging type. Ifthe type of packaging is not repre-sented, check the “Other” box andenter a brief description such as“non-specification bulk bin.”

(25) Enter the appropriate failure codes(found at the end of the instructions):Enter the codes that describe whatfailed on the packaging, how thepackaging failed, and the cause(s)of the failure. Be sure to enter thecodes from the list that correspondsto the particular packaging typeschecked above (#24). Enter themost important failure point in line1. If there is a second failure point,enter in line 2. If there are more

than two failure points, provide ad-ditional information in this format inPart VI. The following explains thecontent of each line:

What Failed: You can enterup to 2 “What Failed” codesto describe the part of the pack-aging that fails and was the im-mediate cause of the release.Often, on a simple packaging,only one code will be required.On more complex packaging,additional entries will helpidentify where that failure oc-curred. The first entry shoulddesignate the specific point offailure, followed by entries thathelp identify where that failureoccurred. For instance, a dete-riorated gasket on a pipeflange on the liquid line wouldhave failure code 121 for gas-ket entered first and failurecode 118 for flange enteredsecond.

How Failed: Enter the “Fail-ure” code that describes how

the corresponding part of thepackaging failed. The primaryway the packaging failedshould be entered first.

Cause(s) of Failure: Enter the“Cause of Failure” code thatdescribes what caused the cor-responding part of the packag-ing to fail in the way it did. Themost probable or fundamentalcause of failure should be en-tered first.

If none of the codes on the list fit exactly,use the closest match and provideadditional detail in Part VI. Also, if youbelieve a better set of codes would bemore descriptive of what failed, how itfailed, and the causes of failure, suggestthem in Part VII.

(26a) Provide the complete packagingidentification markings, if avail-able: Every specification packag-ing, UN or DOT, has a packagingidentification printed or stampedon it or on a plate attached to thepackaging. Examples are pro-vided on the form.

(26b) For Non-bulk, IBC, or non-specifi-cation packaging: Only fill out 26bif the marking is incomplete, de-stroyed, or unknown. Fill in theOuter and Inner packaging typeand Material of Construction infor-mation, as appropriate. If the pack-aging is non-bulk or IntermediateBulk Container (IBC), use the codesin Table 3 to enter the number orletter that applies for either non-bulkor IBC packaging. For non-bulk,IBC or non-specification packagingprovide a description of the pack-aging in the space(s) provided.

(27) Describe the package capacity andthe quantity: Enter the total capacityof the inner and outer package.Also enter the actual amount ofhazardous material that wasshipped in the package, thenumber of packages in theshipment, and the number ofpackages that failed. Pleaseinclude the units of measurement(liter, gallons, pounds, cubic feet,etc.)

(28) Provide package construction andtest information, as appropriate: Inthe case of Non-bulk packagings

6 • INSTRUCTIONS

Table 3 Non-bulk and IBC Packaging Identification Codes.

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or IBCs enter the name of thepackaging manufacturer or thesymbol of the manufacturer only ifcomplete identification markingswere not provided in #26b. Enterthe date of manufacture and theserial number, if applicable. Enterthe last test date if the packagingrequires periodic testing. Alsoinclude the design pressure, shellthickness, head thickness, andservice pressure if the failedpackagings are of the typeindicated in parenthesis after eachquestion. I f the packagingcontained a valve, or other devicethat failed and resulted in ahazardous material release, enterthe valve or device type,manufacturer (i f present andlegible), and model number (ifpresent and legible).

(29) If the package is for RadioactiveMaterials, complete the following:Complete this question only if aradioactive material was involved.Indicate the packaging category,the packaging cer tif ication,certification number, and whichnuclides were present, thetransportation index (TI), activity ofthe nuclides, and the criticalitysafety index.

Part IV: Consequences(30) Result of Incident: Check all boxes

that describe what occurredduring the incident or as a resultof the incident. For example, ina situation where a truckload of55 gallon drums of corrosiveliquids overturns resulting in arelease that contaminates anearby wetlands and stream theboxes “Spi l lage,” “Mater ia lEntered Waterway/StormSewer,” and “EnvironmentalDamage” may apply.

(31) Emergency Response: Check allboxes that correspond with anyemergency response and cleanupcrews that par t ic ipated inresolving the incident. If a firecrew, EMS, or pol ice uni tresponded to the incident, includethe report number.

(32) Damages: You are required toprovide information on estimateddamages if your damages exceed$500.00. This figure includes the

cost of the material lost, propertydamage, vehic le damage,response costs, and clean-upcosts. If you do not know theseamounts at the time you completethe report, or the actual costs arerevised by more than $25,000,you must submit a follow-up reportafter you determine the amounts.The following definitions explaineach of the costs:

Material Loss: Enter the valueof mater ia l re leased andunrecoverable. Base this entryon the amount of materialreleased multiplied by the unitvalue (e.g., price per gallon orprice per pound) as listed onthe shipper’s invoice. If theinvoice is not avai lable,estimate the cost per unit usingthe shipper’s basis.

Carrier Damage: Enter thetotal value of damage incurredby the carr ier. Majorcomponents include costs torepair the damaged vehicleand costs resu l t ing f romdamage to cargo. I f thevehicle is declared “totaled,”enter the insured value of thevehicle. This entry should notinc lude damage to otherproperty or to vehicles ownedby other persons.

Property Damage: Enter thetotal value of costs resultingfrom damage to the propertyof o thers involved in theincident. These include: repairand replacement costs of othervehic les; repair andreplacement costs to buildingsand other fixed facilities; andres torat ion of open landbeyond decontamination andcleanup.

Response Cost: Enter the totalvalue of response cos ts .Response costs are those costsincurred immediately after theincident, and include localemergency response frompolice and fire departmentsand emergency responseteams, as wel l as cos tsincurred by the responsibleparty. Response costs alsoinclude costs to contain thehazardous material released.

Remediation/Cleanup Cost:Enter the total value of the costto cleanup and remediate thesite. Cleanup costs are thosecosts incurred to col lec t ,t ranspor t , and u l t imate lydispose of a l l mater ia lcollected during the responsephase. Remediation costs arethose costs incurred to restorethe incident scene to its pre-incident s ta te, and couldinclude excavation, disposaland replacement ofcontaminated soil, pumping,treatment and re-injection ofcontaminated groundwater, orabsorption and disposal ofhazardous material releasedinto surface water.

(33a) Did the hazardous materialcause or contribute to a humanfatality? If a person was fatallyinjured by contact with thehazardous material or its vaporsor by a fire or explosion thatresulted from the hazardousmaterial, check the “Yes” boxand enter the number of fatalitiesthat resulted directly from thehazardous material.

(33b) Were there human fatalities thatdid not result from the hazardousmaterial? If the fatalities were notcaused directly by the hazardousmaterial, check the “Yes” boxand enter the number offatalities. An example: if apassenger car collided with acargo tank carrying gasolineand the automobile driver waskilled due to the collision, thenthe fatality was not caused bythe hazardous material released.If, however, the accident resultedin the release of gasoline fromthe cargo tank and a resultingfire killed the automobile driver,then the fatality was caused bythe hazardous material.

(34) Did the hazardous materialcause or contribute to a personalinjury? If a person was injuredby contact with the hazardousmaterial or its vapors or by a fireor explosion that resulted fromthe hazardous material, checkthe “Yes” box and enter thenumber of persons injured by thehazardous material.

INSTRUCTIONS • 7

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Hospitalized means admitted to amedical facility, not treated andreleased from a facility, such as ahospital emergency room, wherethe person was never admitted tothe hospital proper. Non-hospitalized individuals are thosewho may have received attentionfrom medical personnel on-site orat a facility (including hospitalemergency room), but were notadmitted to a medical facility.Indicate the number of injuredemployees,emergency responders(firefighters, police, medics, etc.)and members of the generalpublic.

(35) Did the hazardous material causeor contribute to an evacuation? Ifthe incident required theevacuation or removal of personsfrom a specific area because ofpossible or actual contact with thehazardous materials involved inthe incident, check the “Yes” box.Separately specify the numbers ofindividuals from the general publicevacuated and number ofemployees of the facili ty orworkers in the area that wereevacuated. Also provide the totalnumber of individuals evacuated.Indicate the duration of theevacuation (in hours).

(36) Was a transportation artery orfacility closed? If a road ortransportation facility was closeddue to the incident, check the“Yes” box and indicate theduration (in hours) here.

(37) Was the material involved in acrash or derailment? Check the“Yes” box if a hazardous materialwas involved in a crash orderailment. Provide the estimatedspeed and weather conditions atthe time of the crash, such as rain,blowing snow, sleet, icedroadway, sun glare, fog, drypavement, high winds, etc.Indicate if the vehicle overturnedor left the roadway or track.

Part V: Air Incident InformationThis section is for incidents with packagingstransported or intended for transportationby aircraft. If your packaging was nottransported or intended to be transportedby air, skip this section.

(38) Was the shipment on a passengeraircraft? Indicate whether theshipment in question was on acommercial passenger aircraft. Ifso, indicate if the material wastendered (accepted for shipment)as cargo, or was located in apassenger’s baggage, either in thecabin or baggage compartment.

(39) Where did the incident occur orwhere was the incidentdiscovered? Indicate where in thecourse of transpor tation theincident occurred or wasdiscovered.

(40) What phase(s) had the shipmentalready undergone prior to theincident? Check all boxes thatdescribe the transportation phasesthe shipment went through beforethe incident occurred or wasdiscovered.

Part VI: Description of Events andPackaging FailurePlease describe the events involved in theincident to provide us with a betterunderstanding of the incident. Includeinformation that has not been collectedelsewhere on this form, and include specialscenarios, outstanding circumstances, orother information that provides a completepicture of the incident. Describe thesequence of events that led to the incident,the package failure (if any) and actionstaken at the time of discovery. Submitphotographs and diagrams whennecessary for clarification. You maycontinue on additional sheets if necessary.

Part VII: Recommendations/Actions Taken to Prevent FutureIncidentsRecommendations may be preliminary innature, may suggest actions by otherparties, and may be subject to furtherinvestigation, refinement, acceptance, orrejection. Often, it may be beyond theability of the preparer to offerrecommendations, but where suchrecommendations can be made they havethe potential of resulting in importantimprovements with safety benefits. Forinstance, such information can helpcompanies identify common problems andalert the DOT to the need for additionalmeasures such as outreach or broadtraining needs. This information can alsohelp support regulatory changes.

8 • INSTRUCTIONS

Part VIII: Contact InformationProvide the name, title, telephone number,fax number, business name and address,hazmat registration number and emailaddress of the contact person at yourcompany who can answer questions aboutthe information provided on this form.Make sure to check the box that describesthe function of your firm: carrier, shipper,facility owner/operator, or other. If“Other” is checked, describe the function.

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Code What Failed

101 Air Inlet102 Auxiliary Valve103 Basic Material104 Body105 Bolts or Nuts106 Bottom Outlet Valve107 Check Valve108 Chime109 Closure (e.g., Cap, Top, or Plug)110 Cover111 Cylinder Neck or Shoulder112 Cylinder Sidewall - Near Base113 Cylinder Sidewall - Other114 Cylinder Valve115 Discharge Valve or

Coupling116 Excess Flow Valve117 Fill Hole118 Flange119 Frangible Disc120 Fusible Pressure Relief Device or

Element121 Gasket122 Gauging Device123 Heater Coil124 High Level Sensor125 Hose126 Hose Adaptor or Coupling127 Inlet (Loading) Valve128 Inner Packaging129 Inner Receptacle130 Lifting Feature131 Lifting Lug132 Liner133 Liquid Line134 Liquid Valve135 Loading or Unloading Lines136 Locking Bar137 Manway or Dome Cover138 Mounting Studs139 O-Ring or Seals140 Outer Frame141 Piping or Fittings142 Piping Shear Section143 Pressure Relief Valve or

Device - Non-Reclosing144 Pressure Relief Valve or

Device -Reclosing145 Remote Control Device146 Sample Line147 Stub Sill (Tank Car)148 Sump149 Tank Head150 Tank Shell151 Thermometer Well152 Threaded Connection153 Vacuum Relief Valve154 Valve Body155 Valve Seat156 Valve Spring157 Valve Stem158 Vapor Valve159 Vent160 Washout161 Weld or Seam

Code How Failed

301 Abraded302 Bent303 Burst or Ruptured304 Cracked305 Crushed306 Failed to Operate307 Gouged or Cut308 Leaked309 Punctured310 Ripped or Torn311 Structural312 Torn Off or Damaged313 Vented

Code Cause(s) of Failure

501 Abrasion502 Broken Component or Device503 Commodity Self-ignition504 Commodity Polymerization505 Conveyer or Material Handling

Equipment Mishap506 Corrosion - Exterior507 Corrosion - Interior508 Defective Component or Device509 Derailment510 Deterioration or Aging511 Dropped512 Fire, Temperature, or Heat513 Forklift Accident514 Freezing515 Human Error516 Impact with Sharp or Protruding

Object (e.g., nails)517 Improper Preparation for

Transportation518 Inadequate Accident Damage

Protection519 Inadequate Blocking and Bracing520 Inadequate Maintenance521 Inadequate Preparation for

Transportation522 Inadequate Procedures523 Inadequate Training524 Incompatible Product525 Incorrectly Sized Component or

Device526 Loose Closure, Component, or

Device527 Misaligned Material, Component, or

Device528 Missing Component or Device529 Overfilled530 Over-pressurized531 Rollover Accident532 Stub Sill Separation from Tank

(Tank Cars)533 Threads Worn or Cross Threaded534 Too Much Weight on Package535 Valve Open536 Vandalism537 Vehicular Crash or Accident

Damage538 Water Damage

Failure Codes by Packaging TypeGeneral Non-bulk and IBCsCode What Failed

103 Basic Material104 Body105 Bolts or Nuts108 Chime109 Closure (e.g., Cap, Top, or Plug)110 Cover119 Frangible Disc120 Fusible Pressure Relief Device or

Element121 Gasket125 Hose128 Inner Packaging129 Inner Receptacle130 Lifting Feature132 Liner140 Outer Frame143 Pressure Relief Valve or Device -

Non-Reclosing144 Pressure Relief Valve or

Device - Reclosing161 Weld or Seam

Code How Failed



501 Abrasion503 Commodity Self-ignition504 Commodity Polymerization505 Conveyer or Material Handling

Equipment Mishap506 Corrosion - Exterior507 Corrosion - Interior508 Defective Component or Device510 Deterioration or Aging511 Dropped513 Forklift Accident514 Freezing515 Human Error516 Impact with Sharp or Protruding

Object (e.g., nails)517 Improper Preparation for

Transportation521 Inadequate Preparation for

Transportation522 Inadequate Procedures523 Inadequate Training529 Overfilled530 Overpressurized534 Too Much Weight on Package535 Valve Open536 Vandalism537 Vehicular Crash or Accident

Damage538 Water Damage

Failure Codes for All Packaging Types—Complete List

INSTRUCTIONS • 9

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Failure Codes by Packaging Type (continued)

10 • INSTRUCTIONS

Cylinders

Code What Failed

111 Cylinder Neck or Shoulder112 Cylinder Sidewall - Near Base113 Cylinder Sidewall - Other114 Cylinder Valve119 Frangible Disc120 Fusible Pressure Relief Device or Element122 Gauging Device132 Liner143 Pressure Relief Valve or Device - Non-

Reclosing144 Pressure Relief Valve or Device -

Reclosing161 Weld or Seam

Code How Failed

301 Abraded303 Burst or Ruptured304 Cracked306 Failed to Operate307 Gouged or Cut308 Leaked309 Punctured313 Vented



Equipment Mishap506 Corrosion - Exterior507 Corrosion - Interior508 Defective Component or Device510 Deterioration or Aging512 Fire, Temperature, or Heat513 Forklift Accident514 Freezing515 Human Error516 Impact with Sharp or Protruding Object

(e.g., nails)517 Improper Preparation for Transportation519 Inadequate Blocking and Bracing520 Inadequate Maintenance521 Inadequate Preparation for Transportation522 Inadequate Procedures523 Inadequate Training524 Incompatible Product525 Incorrectly Sized Component or Device526 Loose Closure, Component, or Device527 Misaligned Material, Component, or Device528 Missing Component or Device529 Overfilled530 Over-pressurized535 Valve Open536 Vandalism537 Vehicular Crash or Accident Damage

Portable Tanks

Code What Failed

105 Bolts or Nuts106 Bottom Outlet Valve107 Check Valve108 Chime109 Closure (e.g., Cap, Top, or Plug)110 Cover119 Frangible Disc120 Fusible Pressure Relief Device or Element121 Gasket122 Gauging Device125 Hose127 Inlet (Loading) Valve131 Lifting Lug132 Liner135 Loading or Unloading Lines137 Manway or Dome Cover140 Outer Frame141 Piping or Fittings143 Pressure Relief Valve or

Device - Non-Reclosing144 Pressure Relief Valve or Device - Reclosing152 Threaded Connection153 Vacuum Relief Valve161 Weld or Seam

Code How Failed

301 Abraded302 Bent303 Burst or Ruptured304 Cracked305 Crushed306 Failed to Operate307 Gouged or Cut308 Leaked309 Punctured310 Ripped or Torn312 Torn Off or Damaged313 Vented



Equipment Mishap506 Corrosion – Exterior507 Corrosion – Interior508 Defective Component or Device509 Derailment510 Deterioration or Aging511 Dropped512 Fire, Temperature, or Heat514 Freezing515 Human Error517 Improper Preparation for Transportation520 Inadequate Maintenance521 Inadequate Preparation for Transportation522 Inadequate Procedures523 Inadequate Training524 Incompatible Product525 Incorrectly Sized Component or Device526 Loose Closure, Component, or Device527 Misaligned Material, Component, or Device528 Missing Component or Device529 Overfilled530 Overpressurized531 Rollover Accident536 Vandalism537 Vehicular Crash or Accident Damage

Bulk Tank Vehicles—Cargo TankMotor Vehicles (CTMV) and Tank Cars

Code What Failed

101 Air Inlet105 Bolts or Nuts106 Bottom Outlet Valve107 Check Valve110 Cover115 Discharge Valve or Coupling116 Excess Flow Valve117 Fill Hole118 Flange119 Frangible Disc120 Fusible Pressure Relief Device or Element121 Gasket122 Gauging Device123 Heater Coil124 High Level Sensor125 Hose126 Hose Adaptor or Coupling127 Inlet (Loading) Valve131 Lifting Lug132 Liner133 Liquid Line134 Liquid Valve135 Loading or Unloading Lines136 Locking Bar137 Manway or Dome Cover138 Mounting Studs139 O-Ring or Seals141 Piping or Fittings142 Piping Shear Section143 Pressure Relief Valve or Device - Non-Reclosing144 Pressure Relief Valve or Device - Reclosing145 Remote Control Device146 Sample Line147 Stub Sill (Tank Car)148 Sump149 Tank Head150 Tank Shell151 Thermometer Well152 Threaded Connection153 Vacuum Relief Valve154 Valve Body155 Valve Seat156 Valve Spring157 Valve Stem158 Vapor Valve159 Vent160 Washout161 Weld or Seam

Code How Failed



501 Abrasion502 Broken Component or Device503 Commodity Self-ignition504 Commodity Polymerization

(Continued on next page)

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Incident ReportingRequirements

§ 171.15 Immediate notice ofcertain hazardous materialsincidents.

(a) General. As soon as practical butno later than 12 hours after the occurrenceof any incident described in paragraph(b) of this section, each person in physicalpossession of the hazardous material mustprovide notice by telephone to theNational Response Center (NRC) on 800-424-8802 (toll free) or 202-267-2675(toll call). Notice involving an infectioussubstance (etiologic agent) may be givento the Director, Centers for Disease Controland Prevention (CDC), U.S. Public HealthService, Atlanta, Ga., 800-232-0124 (tollfree), in place of notice to the NRC. Eachnotice must include the followinginformation:

(1) Name of reporter;(2) Name and address of personrepresented by reporter;(3) Phone number where reporter canbe contacted;(4) Date, time, and location ofincident;(5) The extent of injury, if any;(6) Class or division, proper shippingname, and quantity of hazardousmaterials involved, if such informationis available; and(7) Type of incident and nature ofhazardous material involvement andwhether a continuing danger to lifeexists at the scene.

(b) Reportable Incident. Atelephone report is required whenever anyof the following occurs during the courseof transportation in commerce (includingloading, unloading, and temporarystorage):(1) As a direct result of a hazardous

material—(i) A person is killed;(ii) A person receives an injuryrequiring admittance to ahospital;(iii) The general public isevacuated for one hour or more;(iv) A major transportation arteryor facility is closed or shut downfor one hour or more; or(v) The operational flight patternor routine of an aircraft is altered;

(2) Fire, breakage, spillage, or suspectedradioactive contamination occursinvolving a radioactive material (seealso § 176.48 of this subchapter);

(3) Fire, breakage, spil lage, orsuspected contamination occursinvolving an infectious substanceother than a diagnostic specimen orregulated medical waste;

(4) A release of a marine pollutantoccurs in a quantity exceeding 450 L(119 gallons) for a liquid or 400 kg(882 pounds) for a solid; or

(5) A situation exists of such a nature(e.g., a continuing danger to life existsat the scene of the incident) that, inthe judgment of the person inpossession of the hazardous material,it should be reported to the NRC eventhough it does not meet the criteria ofparagraph (b) (1), (2), (3) or (4) ofthis section.

(c) Written report. Each personmaking a report under this section mustalso make the report required by§ 171.16 of this Subpart.Note to § 171.15: Under 40 CFR 302.6,EPA requires persons in charge of facilities(including transport vehicles, vessels, andaircraft) to report any release of ahazardous substance in a quantity equalto or greater than its reportable quantity,as soon as that person has knowledge ofthe release, to DOT’s National ResponseCenter at (toll-free) 800-424-8802 or (toll)202-267-2675.

§ 171.16 Detailed hazardousmaterials incident reports.(a) General. Each person in physicalpossession of a hazardous material at thetime that any of the following incidentsoccurs during transportation (includingloading, unloading, and temporarystorage) must submit a HazardousMaterials Incident Report on DOT Form F5800.1 (01-2004) within 30 days ofdiscovery of the incident:

(1) Any of the circumstances set forthin § 171.15(b);(2) An unintentional release of ahazardous material or the dischargeof any quantity of hazardous waste;(3) A specification cargo tank with acapacity of 1,000 gallons or greatercontaining any hazardous materialsuffers structural damage to the ladingretention system or damage thatrequires repair to a system intended toprotect the lading retention system,even if there is no release of hazardousmaterial; or(4) An undeclared hazardous materialis discovered.

Failure Codes by Packaging Type

REPORTING REQUIREMENTS • 11

Bulk Tank Vehicles—Cargo TankMotor Vehicles (CTMV) and Tank CarsCode Cause(s) of Failure

505 Conveyer or Material HandlingEquipment Mishap

506 Corrosion - Exterior507 Corrosion - Interior508 Defective Component or Device509 Derailment510 Deterioration or Aging511 Dropped512 Fire, Temperature, or Heat515 Human Error517 Improper Preparation for

Transportation518 Inadequate Accident Damage

Protection519 Inadequate Blocking and Bracing520 Inadequate Maintenance521 Inadequate Preparation for

Transportation522 Inadequate Procedures523 Inadequate Training524 Incompatible Product525 Incorrectly Sized Component or

Device526 Loose Closure, Component,

or Device527 Misaligned Material, Component,

or Device528 Missing Component or Device529 Overfilled530 Overpressurized531 Rollover Accident532 Stub Sill Separation from Tank

(Tank Cars)533 Threads Worn or Cross Threaded536 Vandalism537 Vehicular Crash or Accident

Damage

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12 • REPORTING REQUIREMENTS

(b) Providing and retainingcopies of the report. Each personreporting under this section must—

(1) Submit a written HazardousMaterials Incident Report to theInformation Systems Manager, PHH-63, Pipeline and HazardousMaterials Safety, Department ofTransportation, Washington, DC20590-0001, or an electronicHazardous Material Incident Reportto the Information System Manager,PHH-63, Pipeline and HazardousMaterials Safety Administration,Department of Transportation,Washington, DC 20590-0001 athttp://hazmat.dot.gov;(2) For an incident involvingtransportation by aircraft, submit awritten or electronic copy of theHazardous Materials IncidentReport to the FAA Security FieldOffice nearest the location of theincident; and(3) Retain a written or electronic copyof the Hazardous Materials IncidentReport for a period of two years atthe reporting person’s principal placeof business. If the written or electronicHazardous Materials Incident Reportis maintained at other than thereporting person’s principal place ofbusiness, the report must be madeavailable at the reporting person’sprincipal place of business within 24hours of a request for the report byan authorized representative orspecial agent of the Department ofTransportation.

(c) Updating the incident report.A Hazardous Materials Incident Reportmust be updated within one year of thedate of occurrence of the incidentwhenever:

(1) A death results from injurycaused by a hazardous material;(2) There was a misidentificationof the hazardous material orpackaging information on a priorincident report;(3) Damage, loss or related costthat was not known when theinitial incident report was filedbecomes known; or(4) Damage, loss, or related costchanges by $25,000 or more, or10% of the prior total estimate,whichever is greater.

(d) Exceptions. Unless a telephonereport is required under the provisions of§ 171.15 of this part, the requirements

of paragraphs (a), (b), and (c) of thissection do not apply to the followingincidents:

(1) A release of a minimal amountof material from—(i) a vent, for materials for whichventing is authorized;(ii) the routine operation of a seal,pump, compressor, or valve; or(iii) connection or disconnection ofloading or unloading lines,provided that the release does notresult in property damage.(2) An unintentional release ofhazardous material when:

(i) The material is properlyclassed as—(A) ORM-D; or(B) a Packing Group IIImaterial in Class or Division3, 4, 5, 6.1, 8, or 9;(ii) Each packaging has acapacity of less than 20 liters(5.2 gallons) for liquids or lessthan 30 kg (66 pounds) forsolids;(iii) The total aggregate releaseis less than 20 liters (5.2gallons) for liquids or less than30 kg (66 pounds) for solids;and(iv) The material is not—(A) offered for transportation ortransported by aircraft,(B) a hazardous waste, or(C) an undeclared hazardousmaterial.(3) An undeclared hazardousmaterial discovered in an airpassenger’s checked or carry-on baggage during the airportscreening process. (Fordiscrepancy reporting bycarriers, see § 175.31 of thissubchapter.)

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Incident Reporting Guidelines • 17

HAZARDOUS MATER IALS

INCIDENT REPORT ING

AND REQUIREMENTS

EFFECTIVE JANUARY 1, 2005



1200 New Jersey Avenue, SE, PHH-50Washington, DC 20590-0001

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