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Attachment 2 <br /> Discharge Report Form <br /> Discharge/Discovery Date Time <br /> Facility Name <br /> Facility Location(Address/Lat- <br /> LonglSection Township Range) <br /> Name of reporting individual "Telephone # <br /> Type of material discharged Estimated total quantity Gallons/Barrels <br /> discharged <br /> Source of the discharge Media affected ❑ Soil <br /> ❑ Water(specify) <br /> ❑ Other(specify) <br /> Actions taken <br /> Damage or injuries ❑ No❑ Yes (specify) Evacuation needed? ❑ No ❑ Yes(specify) <br /> 14 <br />