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Wisconsin - Form 4400-225 Notification for Hazardous Substance Discharge

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Form 4400-225 (R 06/17)
Notification For Hazardous Substance Discharge
(Non-Emergency Only)
State of Wisconsin
Department of Natural Resources
PO Box 7921, Madison WI 53707-7921
dnr.wi.gov
Emergency Discharges / Spills should be reported via the 24-Hour Hotline: 1-800-943-0003
Notice: Hazardous substance discharges must be reported immediately according to s. 292.11 Wis. Stats. Non-emergency hazardous
substance discharges may be reported by telefaxing or e-mailing a completed report to the Department, or calling or visiting a Department office in
person. If you choose to notify the Department by telefax or by email, you should use this form to be sure that all necessary information is included.
However, use of this form is not mandatory. Under s. 292.99, Wis. Stats., the penalty for violating the reporting requirements of ch. 292 Wis. Stats.,
shall be no less than $10 nor more than $5000 for each violation. Each day of continued violation is a separate offense. It is not the Department’s
intention to use any personally identifiable information from this form for any purpose other than program administration. However, information
submitted on this form may also be made available to requesters under Wisconsin’s Open Records Law (ss. 19.31 – 19.39, Wis. Stats.).
Confirmatory laboratory data should be included with this form, to assist the DNR in processing this Hazardous Substance Release
Notification.
Complete this form. TYPE or PRINT LEGIBLY. NOTIFY appropriate DNR region (see next page) IMMEDIATELY upon discovery of a
potential release from (check one):
Underground Petroleum Storage Tank System (additional information may be required for Item 6 below)
Aboveground Petroleum Storage Tank System
Dry Cleaner Facility
Other - Describe:
ATTN DNR: R & R Program Associate
Date DNR Notified:
1. Discharge Reported By
Name Firm
Phone Number (include area code)
Mailing Address Email
2. Site Information
Name of site at which discharge occurred. Include local name of site/business, not responsible party name, unless a residence/vacant
property.
Location: Include street address, not PO Box. If no street address, describe as precisely as possible, i.e., 1/4 mile NW of CTHs 60 &
123 on E side of CTH 60.
Municipality: (City, Village, Township) Specify municipality in which the site is located, not mailing address/city.
County Legal Description:
¼ of ¼ Section , Town
N,
Range
E W
WTM:
X Y
3. Responsible Party (RP) and/or RP Representative
Responsible Party Name: Business or owner name that is responsible for cleanup. If more than one, list all. Attach additional pages as
necessary.
A local governmental unit claiming an exemption from state Spill Law and Solid Waste Management responsibilities for the
discharge being reported, per Wis. Stat. §§ 292.11(9)(e) and 292.23, should: 1) check this box; 2) review DNR publication RR-055;
and 3) provide documentation to DNR that demonstrates compliance with the statutory requirements of the liability exemptions.
Local governmental units may also request a fee-based liability clarification letter from DNR by using DNR Form 4400-237.
Contact Person Name (if different)
Phone Number
Email
Mailing Address City State ZIP Code
Responsible Party Name: Business or owner name that is responsible for cleanup. If more than one, list all. Attach additional pages as
necessary.
Contact Person Name (if different)
Phone Number
Email
Mailing Address City State ZIP Code
(continued)
Page 1 of 3
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Form 4400-225 (R 06/17)
Notification For Hazardous Substance Discharge (Non-Emergency Only)
4. Hazardous Substance Information
Identify hazardous substance discharged (check all that apply):
VOCs
PCE
TCE
Other Chlorinated
Diesel
Fuel Oil
Gasoline
Hydraulic Oil
Jet Fuel
(VOCs continued)
Mineral Oil
Waste Oil
Petroleum-Unknown Type
PAHs
PCBs
Cyanide
Leachate
Manure
Metals
Arsenic
Chromium
Lead
Other:
Unknown
Pesticides:
Fertilizer:
RCRA Hazardous Waste:
Other:
Enter "K" for known/confirmed or "P" for potential for all that apply.
Air Contamination
Co-mingled (Petroleum & Non-Petroleum)
Contamination in Fractured Bedrock
Contamination Within 1 Meter of Bedrock
Contaminated Private Well
Contaminated Public Well
Contamination in Right of Way
5. Impacts to the Environment Information
Fire Explosion Threat
Free Product
Groundwater Contamination
Off-Site Contamination
Sanitary Sewer Contamination
Storm Sewer Contamination
Sediment Contamination
Soil Contamination
Soil Gas Contamination
Sub-slab Vapor Contamination
Surface Water Contamination
Within 100 ft of Private Well
Within 1000 ft of Public Well
Contamination was discovered as a result of:
Date
Tank closure assessment Site assessment
Date
Other - Describe:
Date
Lab results:
Lab results will be faxed upon receipt Lab results are attached
Additional Comments: Include a brief description of immediate actions taken to halt the release and contain or cleanup
hazardous substances that have been discharged.
Other (specify):
6. Federal Energy Act Requirements (Section 9002(d) of the Solid Waste Disposal Act (SWDA))
For all confirmed releases
from USTs occurring after
9/30/2007 please provide
the following information:
Does not apply.
Other (specify):
Tank
Piping
Dispenser
Submersible Turbine Pump
Delivery Problem
Source Cause
Spill
Overfill
Corrosion
Physical or Mechanical Damage
Installation Problem
Other (does not fit any of above)
Unknown
Contact information to report non-emergency releases in DNR's five regions are as follows:
Northeast Region (FAX: 920-662-5413); Attention -- R&R Program Associate: DNRRRNER@wisconsin.gov
Brown, Calumet, Door, Fond du Lac (except City of Waupun - see South Central Region), Green Lake, Kewaunee, Manitowoc,
Marinette, Marquette, Menominee, Oconto, Outagamie, Shawano, Sheboygan, Waupaca, Waushara, Winnebago counties
Northern Region (FAX: 715-623-6773); Attention -- R&R Program Associate: DNRRRNOR@wisconsin.gov
Ashland, Barron, Bayfield, Burnett, Douglas, Forest, Florence, Iron, Langlade, Lincoln, Oneida, Polk, Price, Rusk, Sawyer, Taylor,
Vilas, Washburn counties
South Central Region (FAX: 608-273-5610); Attention -- R&R Program Associate: DNRRRSCR@wisconsin.gov
Columbia, Dane, Dodge, Fond du Lac (City of Waupun only), Grant, Green, Iowa, Jefferson, Lafayette, Richland, Rock, Sauk,
Walworth counties
Southeast Region (FAX: 414-263-8550); Attention -- R&R Program Associate: DNRRRSER@wisconsin.gov
Kenosha, Milwaukee, Ozaukee, Racine, Washington, Waukesha counties
Page 2 of 3
Submit Form to NER
Submit Form to NOR
Submit Form to SCR
Submit Form to SER
Form 4400-225 (R 06/17)
Notification For Hazardous Substance Discharge (Non-Emergency Only)
West Central Region (FAX: 715-839-6076); Attention -- R&R Program Associate: DNRRRWCR@wisconsin.gov
Adams, Buffalo, Chippewa, Clark, Crawford, Dunn, Eau Claire, Jackson, Juneau, LaCrosse, Marathon, Monroe, Pepin, Pierce,
Portage, St. Croix, Trempealeau, Vernon, Wood counties
Page 3 of 3
Submit Form to WCR
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Completed 26 May 2020

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