Form EPIC-143 National Clandestine Laboratory Seizure Report

NATIONAL CLANDESTINE LABORATORY SEIZURE REPORT

OMB NO. 1117-0042 TYPE OF REPORT*

☐ Lab Seizure ☐ Chem/Glassware/Equip Seizure (Only) ☐ Dumpsite Seizure (Only)

I

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

Seizure Date * (MMDDYYYY) Enter Here

Agency * Enter Here

ORI * Enter Here

Agency City * Enter Here

Agency State * Enere

Case or File Number * Enter Here

File Title Enter Here

☐ Authorized Central Storage (ACS) Cleanup If yes, site ID: Enter Here

Reporting Officer/Agent Name * (Last, First) Enter Here

Telephone Number * ( E ) Enter Here

COPS Number (DEA ‘S’ Number) Enter Here

II

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

☐ Apartment/Condo

☐ Family Dwelling

☐ Outbuilding

☐ Vehicle

☐ Other – Describe Enter Here

☐ Business

☐ Hotel/Motel

☐ School/Univ.

☐ Vessel

☐ Dumpster

☐ Open – No Structure

☐ Storage Facility

III

Seizure Neighborhood (Check most appropriate)

☐ Commercial/Industrial

☐ Public Land – Name

☐ Rural

☐ Suburban

☐ Urban

☐ Other – Describe Enter Here

IV

Estimated Lab Capacity (Based on seized chemicals, glassware, and equipment on site) (Mandatory if lab seizure is checked)

☐ Under 2 oz.

☐ 2 – 8 oz.

☐ 9 oz. – 1 lb.

☐ 2 – 9 lbs

☐ 10 – 19 lbs.

☐ 20 lbs. or Greater

V

Laboratory Status (Check all that apply) (Mandatory if lab seizure is checked)

☐ Operational – Not in Production

☐ Abandoned

☐ Explosion/Fire

☐ Other – Describe: Enter Here

☐ Operational – In Production

☐ Boxed/Dismantled

VI

Laboratory Type (Check all that apply)

☐ Cocaine Conversion (Crack)

☐ Honey Oil/THC Extraction (liq)

☐ Methamphetamine (Meth)

☐ Methcathinone

☐ Other – Describe Enter Here

☐ Fentanyl

☐ LSD

☐ Meth/Ice Conversion

☐ PCP

☐ GHB/GBL

☐ MDMA

☐ Meth/Reconstitution

☐ PSE Tablet Extraction

VII

Primary Methamphetamine Manufacturing Process (Required for Lab Seizure Report)

☐ Pseudoephedrine/Phosphorus/Hydriodic Acid/Iodine Reduction

☐ P2P – Methylamine

☐ Other – Describe Enter Here

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

☐ One Pot Method/Shake & Bake

VIII

THC Manufacturing Process

☐ THC Extraction Chemical/Wet Method

☐ THC Extraction Dry Method

IX

Seizure/Laboratory Address

Street# Er H

Dir. (N., S., E., W., etc.) Enr Here

Street Name Enterre

Suffix (St., Ave., etc.) Enter e

Unit # (Apt) Entee

Box # Entere

City Enterre

County* Enterre

State* Entre

Zip Code Enterre

Latitude/Longitude Enter

X

Chemist and Cleanup Personnel

Chemist on Site: ☐ None ☐ State/Local ☐ DEA

Hazmat Contractor Used: ☐ Yes ☐ No

Name of Hazmat Contractor: Enter Here

Evaluation of Hazmat Contractor: ☐ Excellent ☐ Satisfactory ☐ Poor ** **(Provide details in Remarks Section)

XI

Persons Affected (Children are mandatory – indicate 0 when none were affected) (Check all that apply and indicate number)

☐ Total Children Affected

#

☐ Child Injured

#

☐ Child Killed

#

☐ Law Enforcement Injured

#

☐ Law Enforcement Killed

#

☐ Subject Injured

#

☐ Subject Killed

#

Remarks (Describe How People were Injured or Killed): Remarks

XII

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

Type (Handgun, Rifle, etc.)

Number

Serial No.

Description (Make, Model, & Caliber)

Enter Here

#

Enter Here

Enter Here

Enter Here

#

Enter Here

Enter Here

Booby Trap – Describe: Describe

XIII

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

☐ Amphetamine

amt

unit

☐ LSD

amt

unit

☐ Methamphetamine

amt

unit

☐ Cocaine

amt

unit

☐ Marijuana

amt

unit

☐ Methcathinone

amt

unit

☐ Fentanyl

amt

unit

☐ MDMA

amt

unit

☐ PCP

amt

unit

☐ GHB/GBL

amt

unit

XIV

Subject Information

Last Name (Paternal) Enter Here

Last Name (Maternal) Enter Here

First Name Enter Here

Middle Name Enter Here

Alias/Moniker Enter Here

Generation (Jr., Sr., etc.) Eer Here

☐ Male ☐ Female

Race C

Nationality (US, MX, etc.) Enter Here

DOB (MMDDYYYY) Enter Here

Alt DOB (MMDDYYYY) Enter Here

Height Enter Here

Weight (lbs) Enter Here

Hair Color Enter Here

Eye Color Color

Arrested ☐ Yes ☐ No

Phone Type: ☐ Home ☐ Cell/Mobile ☐ Pager Phone Number: ( e ) Enter Here

Subject Residence Information

Street Number #

Dir. (N., S., E., W., etc.) Enter Here

Street Name Enter Here

Unit # (Apt) Enter Here

Box # Enter Here

City Enter Here

County Enter Here

State Enter Here

Country Enter Here

Zip Code Enter Here

Social Security Number Enter Here

Driver License Number/State Enter Here

FBI Number Enter Here

Alien Registration Number Enter Here

NADDIS Number Enter Here

Other Numbers Enter Here

XV

Remarks Section

Enter Here

Technical Assistance: 915-760-2135

Internet: https://www.epic.gov

E-mail Address: CLS@epic.gov

Mailing Address: El Paso Intelligence Center ATTN: CLS 11339 SSG Sims Street El Paso, Texas 79918-8098

USE ADDITIONAL PAGES AS NECESSARY – LOCAL REPRODUCTION AUTHORIZED

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