Form EPIC 143 EPIC 143 National Clandestine Laboratory Seizure Report

OMB NO. 1117-0042
EXP. DATE 8/31/2013

SUBMIT

E-Form version 1.0.1

NATIONAL CLANDESTINE
LABORATORY SEIZURE REPORT

TYPE OF REPORT*
Lab Seizure
Chem/Glassware/Equip Seizure (Only)
Dumpsite Seizure (Only)

Entered data must meet 28 CFR Part 23 guidelines.
I

Reporting Office (An asterisk symbol (*) indicates a mandatory field)

Seizure Date * (MM-DD-YYYY) Agency *
Agency State *

ORI *

Case or File Number *

File Title

E143 ID (for EPIC use - autogenerated)

Reporting Officer/Agent Name * (First, Last)

II

Agency City *

Telephone Number *
(
)

COPS Number (DEA ‘S’ Number) *

Seizure Location* (Check one – put additional information in Remarks Section)
Apartment/Condo

Hotel/Motel

Family Dwelling

Storage Facility

Business

Outbuilding

Vehicle

Dumpster

Open – No Structure

Other – Describe in remarks

III

Seizure Neighborhood (Check most appropriate)
Commercial/Industrial

Rural

Suburban

Public Land – Describe in remarks

IV

Urban

Other – Describe in remarks

Estimated Lab Capacity (Based on seized chemicals, glassware, and equipment on site) (Mandatory if lab seizure is checked)
Under 2 oz. (less than 1 gal)

V

2 – 8 oz. (1-5 gal)

9 oz. – 1 lb. (6-10 gal)

2 – 9 lbs.(11-14 gal)

10 – 19 lbs.(>= 15 gal)

20 lbs. or Greater

Laboratory Status (Check all that apply) (Mandatory if lab seizure is checked)
Operational – Not in Production

Abandoned

Explosion/Fire

Operational – In Production

Boxed/Dismantled

Other – Describe in remarks

VI

Lab Manufacturing Process (Check ONLY one)
Ephedrine/Phosphorus/Hydriodic Acid Reduction
and/or Iodine Reduction

Ephedrine/Lithium, Sodium or Potassium/
Anhydrous Ammonia (Nazi/Birch)

Ephedrine Tablet Extraction

Pseudoephedrine/Phosphorus/Hydriodic Acid
and/or Iodine Reduction

Pseudoephedrine/Lithium, Sodium or Potassium/
Anhydrous Ammonia (Nazi/Birch)

Pseudoephedrine Tablet Extraction

P2P/Methylamine

Hydriodic Acid Manufacturing

Ice Conversion

Hydrogenation

Anhydrous Ammonia Manufacturing

One-Pot Method
Other - Describe in remarks

VII
Laboratory Equipment (Continue in Remarks)
Homemade/Improvised
Professional/Retail
VIII

Store Name:
City:

Laboratory Type (Check all that apply)

Amphetamine

Tablet Extraction

Anhydrous Ammonia

Methamphetamine

Ice Conversion

Hydriodic Acid

GHB

MDMA

Methcathinone

PCP

Other – Describe in remarks

IX

Seizure/Laboratory Address* (Either County/State or Lat/Long must be entered)

Street #

Dir. (E, S, etc.)

State

X

County* (select state first)

Street Name

Suffix (St., Ave., etc.)

City (select state first)

Zip Code

Latitude (decimal)

Unit # (Apt) Box #
Longitude (decimal)

Chemist and Cleanup Personnel*
Hazmat Contractor
Used:
Yes
No

Chemist on Site:
None

State/Local

DEA

Name of Hazmat Contractor:

Evaluation of Hazmat Contractor:
Excellent

Satisfactory

Poor **

**(Provide details in Remarks Section)

XI

Persons Affected (Children are mandatory – indicate 0 when none were affected)
Total Children Affected

(#

0 )

Law Enforcement Killed

(#

)

0

Child Injured

(#

Suspect Injured

(#

0

)

Child Killed

(#

0

)

Suspect Killed

(# 0

0 )

Law Enforcement Injured

(# 0

)

)

Describe How People were Injured or Killed in remarks section.

FORM EPIC 143 (05-2010)

Previous Editions Obsolete

Page 1 of 4

NATIONAL CLANDESTINE LABORATORY SEIZURE REPORT - CONTINUED

XII

Weapons/Explosives Seized (Check all that apply and continue in Remarks Section)

Type (Handgun, Rifle, etc.)

Number

Serial No.

Description (Make, Model, & Caliber)

Booby Trap – Describe:

XIII

Quantity of All Drugs Seized at Lab Site (Check all that apply/Specify amount & unit of measure)

Amphetamine

LSD

Cocaine
COCAINE
POWDER

MDMA

GHB/GBL

XIV

Marijuana

Amt

Methcathinone

Amt

PCP

Amt

Precursor/Chemical Source (If more than one precursor, continue in Remarks Section)

Specify Precursor:

Source:

Store Name:

XV

MARIJUANA

Methamphetamine
METH
POWDER

Chemical Company

Convenience Store

City:

State:

Country:

Retail Outlet

Unknown

Other – Describe in remarks

Precursor Agents/Catalysts/Solvents/Reagents Seized (Check all that apply/Specify unit of measure)

Precursor Agents (If Ephedrine or Pseudoephedrine is selected, Packaging category is mandatory)
Ephedrine

Amt

Unit of Measure

Pseudoephedrine

Packaging:*

Unknown

Powder

Tablets

Blister Packs

Source:

Domestic

Canada

Mexico

India

Packaging:*

China Source:

Unit of Measure

Amt

Unknown

Powder

Tablets

Domestic

Canada

Mexico

Brand Name(s):

Blister Packs
India

China

NOTE: Brand Names and Lot Numbers for chemicals
other than ephedrine and pseudoephedrine should be
entered in the Remarks Section.

Lot Number(s):
Benzaldehyde

Amt

GBL

Amt

Piperidine

Benzylchloride

Amt

Methylamine

Amt

P2P

Benzylcyanide

Amt

Phenylpropanolamine

Catalysts/Solvents/Reagents - Enter amount and unit of measure
Amt

Unit of Measure

Amt

Unit of Measure

Amt

Unit of Measure

Acetone

Grignard

PCC

Amt

Alcohol

Hexamine

Phenylacetic Acid

Amt

Aluminum

Hydriodic Acid (HI)

Phosphorus

Ammonium Nitrate

Hydrochloric Acid (Muriatic)

Potassium Chlorate
(Perchlorate)

Ammonium Sulfate

Hydrogen Chloride Gas

Potassium Cyanide

Amt

Anhydrous Ammonia

Hydrogen Gas

Potassium Metal

Amt

Benzene

Hydrogen Peroxide

Potassium Nitrate

Amt

Bromobenzene

Hypophosphorous Acid

Potassium Permanganate

Amt

Castor Seeds

Iodine (Crystals)

Sodium Chloride (Salt)

Amt

Caustic Soda

Iodine (Tincture)

Sodium Cyanide

Amt

Charcoal Lighter Fluid

Lithium Metal

Sodium Dichromate

Amt

Chloroform

Magnesium

Sodium Hydroxide (Lye)

Amt

Chromium Trioxide

Mercuric Chloride

Sodium Metal

Amt

Citric Acid

Methanol

Sulfuric Acid

Amt

Coleman/Camping Fuel

Methyl Ethyl Ketone (MEK)

Thionyl Chloride

Cyclohexanone

Methylsulfonylmethane
(MSM)

Toluene

Ether

Naphtha

Urea

Ethylene Glycol

Nitric Acid

Other

Freon

Nitromethane

FORM EPIC 143 (05-2010)

Previous Editions Obsolete

Amt
Amt

Amt
Amt
Amt

Page 2 of 4

NATIONAL CLANDESTINE LABORATORY SEIZURE REPORT - CONTINUED

XVI

Criminal Affiliation (If applicable - Type and name are mandatory if entered)

Asian Org

Mexican Org

Militia Group

Motorcycle Gang

Other

XVII

Organized Crime

Middle Eastern Group

Organization/Gang/Group Name:

Suspect/Criminal Business/Criminal Vehicle Information

Suspect #1 Information
Last Name (Paternal)

Last Name (Maternal)

First Name

Alias/Moniker

Generation
(Jr., Sr., etc.)

DOB (MM-DD-YYYY)
Phone Type:

Home

Alt DOB (MM-DD-YYYY)
Cell/Mobile

Suspect Residence Information
Street Number
Dir. (E., S., etc.)
State

County

Male

Female

Height (in) Weight (lbs)

Pager

Race

Nationality (US, MX, etc.)

Hair Color Eye Color

Arrested

Yes

No

Phone Number

Street Name
City

Anderson

Middle Name

Unit # (Apt)

Box #

Country

Abbott

Zip Code

Involvement (Role) and Identification Numbers
Cook/Chemist

Enforcer

Smuggler

Distributor

Financier

Broker

Chemical Courier
Other – Describe in remarks

Social Security Number

Driver License Number/State

FBI Number

Alien Registration Number

NADDIS Number

Other Numbers

Suspect #2 Information
Last Name (Paternal)

Last Name (Maternal)

Alias/Moniker

Phone Type

Home

Alt DOB (MM-DD-YYYY)
Cell/Mobile

Suspect Residence Information
Street Number
Dir. (E., S., etc.)
State

First Name
Generation
(Jr., Sr., etc.)

DOB (MM-DD-YYYY)

County

Criminal Associate

Middle Name
Male

Height (in) Weight (lbs)

Pager

Female

Race

Nationality (US, MX, etc.)

Hair Color Eye Color

Arrested

Yes

No

Phone Number

Street Name

Unit # (Apt)

Box #

City

Involvement (Role) and Identification Numbers
Cook/Chemist

Enforcer

Smuggler

Distributor

Financier

Broker

Chemical Courier
Other – Describe in remarks

Social Security Number

Driver License Number/State

FBI Number

Alien Registration Number

NADDIS Number

Other Numbers

Suspect #3 Information
Last Name (Paternal)

Last Name (Maternal)

Alias/Moniker

Phone Type

Home

Alt DOB (MM-DD-YYYY)
Cell/Mobile

Suspect Residence Information
Street Number
Dir. (E., S., etc.)
State

First Name
Generation
(Jr., Sr., etc.)

DOB (MM-DD-YYYY)

County

Middle Name
Male

Height (in) Weight (lbs)

Pager

Criminal Associate

Female

Race

Hair Color Eye Color

Nationality (US, MX, etc.)

Arrested

Yes

Phone Number

Street Name
City

Unit # (Apt)
Country

Box #
Zip Code

No

NATIONAL CLANDESTINE LABORATORY SEIZURE REPORT - CONTINUED
Involvement (Role) and Identification Numbers
Cook/Chemist

Enforcer

Smuggler

Chemical Courier

Distributor

Financier

Broker

Other – Describe in remarks

Social Security Number

Driver License Number/State

FBI Number

Alien Registration Number

NADDIS Number

Other Numbers

Criminal Associate

Criminal Business Information (Include all a.k.a.’s)
Business Name:

Business AKA:

Street Number

Dir. (E., S., etc.)

City

Street Name

Unit # (Apt)

County

Phone Type

Regular

Cell

State
Fax

NADDIS Number

Phone Number

(

Country

Box #

Zip Code

)

Other Numbers (TECS, Case, etc.)

Criminal Vehicle Information (If applicable - if entered, vehicle type is mandatory)
License Plate Number

Temporary License Plate #

VIN Number

State

Type (Car, SUV, Pickup, etc.)

Model

Year

Owner Type

Country

Seized

Yes

No

Make
Privately Owned

Rental

Other

XVIII DEA Reporting Only
GDEP Identifier

Special Agent’s Name * (First, Last)
Yes

XIX

Enter DEA Office Identifier and Case Number in remarks,
if applicable

Special Operations Division Supported Case
Phone # *
No

Acknowledgement that the Clan Lab Seizure has been reported to CCF via a standard seizure form and submitted to the
Division Asset Removal Group for processing and input into the Consolidated Asset Tracking System.

Remarks Section

Submission status reports and NSS incident numbers will be sent to the POC e-mail address

Internet: https://www.esp.gov

915-760-2135: Technical Assistance

Please do not e-mail a PDF file, as these files cannot be processed. Click the "SUBMIT" button and e-mail the Form Data
File (FDF) to: epic_dropbox@epic.gov or as directed by State/Local Clan Lab Coordinator.
POC e-mail address(es) - separate with semicolon and use no spaces

FORM EPIC 143 (05-2010)

SUBMIT

Previous Editions Obsolete

Page 4 of 4