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pdfOMB 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
File Type | application/pdf |
File Title | EPIC CLS 143 |
Author | Jose Loya |
File Modified | 2012-05-16 |
File Created | 2011-12-20 |