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NOV 0 4 2013 <br />ATTACHMENT 4 — Discharge Notification Form <br />Ver. 1-E-doc-3-18-10 <br />In the event of a discharge of oil to navigable waters or adjoining shorelines, the following information will be provided to the National <br />Response Center [also see the notification information provided in Section 7 of the Plan]: <br />Table G-20 Information provided to the National Response Center in the Event of a Discharge <br />Discharge/Discovery Date <br />Time <br />Facility Name <br />Facility Location (Address/Lat- <br />Long/Section Township Range) <br />Name of reporting individual <br />Telephone # <br />Type of material discharged <br />Estimated total quantity <br />discharged <br />Gallons/Barrels <br />Source of the discharge <br />Media affected <br />❑ Soil <br />❑ Water (specify) <br />❑ Other (specify) <br />Actions taken <br />Damage or injuries <br />❑ No ❑ Yes (specify) <br />Evacuation needed? <br />❑ No ❑ Yes (specify) <br />Organizations and individuals <br />contacted <br />❑ National Response Center 800-424-8802 Time <br />❑ Cleanup contractor (Specify) Time <br />❑ Facility personnel (Specify) Time <br />❑ State Agency (Specify) Time <br />❑ Other (Specify) Time <br />Facility Name: Stockton Tri Industries, Inc. Page 18 Tier I Qualified Facility SPCC Plan <br />