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OCR for page 122
APPENDIX F Sample Railroad Data Request Form F-1

OCR for page 122
F-2 Guidebook for Conducting Local Hazardous Materials Commodity Flow Studies [Company LOGO] REQUEST FOR HAZARDOUS MATERIALS COMMODITY FLOW INFORMATION Organization Requesting Information: _______________________________________ Contact Person: _______________________________________________ Phone Number: _______________________________________________ Email Address: _______________________________________________ Mailing Address: _______________________________________________________ (Street Address) ___________________________________________________ (City, State, Zip) Geographical Description of Area for Study: _________________________________________ _____________________________________________________________________________ Preferred Method to Receive Report: Email U.S. Mail (Mark One) By signing below I acknowledge and agree to the terms set forth by [RAILROAD NAME] for use and dissemination of the [RAILROAD'S] Hazardous Materials Commodity Flow Information. [RAILROAD'S NAME] considers this information to be restricted information of a security sensitive nature. I thus affirm and agree that the information provided by [RAILROAD NAME] in this report will be used solely for and by bona fide emergency planning and response organizations for the expressed purpose of emergency and contingency planning. This information will not be distributed publicly in whole or in part without the expressed written permission of [RAILROAD NAME]. (Signature of Person Requesting Commodity Flow Information) Return Completed Form to: [INSERT RAILROAD NAME AND ADDRESS] For [RAILROAD] Use Only [PERSON RESPONSIBLE FOR APPROVAL]: ___Yes___ No Date: __________ Hazardous Materials Service Support: Date Request Received: Time Period Covered: Date Report Sent: Report sent via: Email U.S. Mail