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Simplot Grower Solutions—4863 Carpenter,Stockton CA Date: September 2019 <br /> SPILL PREVENTION CONTROL AND COUNTERMEASURE PLAN Page: 37 <br /> 1. Person completing form: Phone: <br /> 2. Facility: <br /> Name Location <br /> 3. Type of Incident: (check all that apply) Liquid Dry <br /> ❑ Fertilizer Release <br /> ❑ Hazardous ❑ Gas/Diesel <br /> ❑ Non-hazardous ❑ Oil release <br /> ❑ Pesticide ❑ Complaint from neighbor or public <br /> ❑ Hazardous ❑ Other: <br /> ❑ Non-hazardous <br /> 4. Date of Incident, Inspection or Complaint: Time: <br /> 5. Substance(s) Released: <br /> Units (lbs., <br /> 6. Amount Released: gallons) <br /> 7. Exact Location of Spill: <br /> 8. Weather Conditions: <br /> 9. If the incident was a spill, did it reach: (check all that apply) <br /> Paved surface, contained &cleaned up Soil, adjacent to property <br /> Soil contamination, on site only Surface water <br /> Storm drain Ground water <br /> Sanitary drain Other(describe on back) <br /> 10. Cause of incident or reason for inspection/complaint: <br /> 11. If a chemical release incident, it was reported to <br /> INIMEDIATELY(WITHIN 15 MINUTES)REPORT SPILLS OR RELEASES EWEEDING RQ TO THE <br /> NATIONAL RESPONSE CENTER 800-424-8802 <br /> Date/Time Reported Name of Individual Reported to <br /> Location Supervisor <br /> AOM <br /> EH&S Mgr_ <br /> National Emergency Response Center Report Number: <br /> State Emergency Response Center <br /> Local Emergency Response Center <br /> State Environmental Agency <br /> Local Fire Department <br /> Other(Describe on back of page) <br /> 12. Remedial Action Taken or Inspector's Findings: (describe) <br /> 13. Steps Taken (or proposed)to Prevent Reoccurrence: <br /> Submit to Environmental, Health&Safety Manager as soon as possible following the incident <br /> Signed Date <br />