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❑� Northwest Pipe Spill Prevention, Control, and Countermeasure (SPCC) Plan 49 <br /> �--. Company Tracy Plant <br /> Appendix D Discharge Notification Form <br /> Discharge Notification Form <br /> Part A: Discharge Information <br /> General Information when reporting a spill to outside authorities: <br /> Name: Northwest Pipe Company— Tracy Plant <br /> Address: 10100 W. Linne Road, Tracy, CA 95377 <br /> Telephone: (951) 928-3446 <br /> Owner/Operator: Northwest Pipe Company <br /> 201 NE Park Plaza Drive, Suite 100, Vancouver, WA 98684 <br /> Primary Contact: Denisse Vignon Work: (209) 666-8967 <br /> Fernandez Cell (24 ours): (832) 833-5697 <br /> Type of oil: Discharge Date and Time: <br /> Quantity Released: Discovery Date and Time: <br /> Quantity Released to a Water Body: Discharge Duration: <br /> Location/Source: <br /> Action(s)taken to stop, remove, and mitigate impacts of the discharge: <br /> Affected media(select all that apply): <br /> ❑ Air ❑ Soil ❑ Dike/Berm/Oil-Water Separator <br /> ❑ Water ❑ Stormwater Sewer/POTW ❑ Other: <br /> Notification Person: Telephone Contact: <br /> Business: <br /> 24-Hr: <br /> Nature of discharges, environmental/health effects and damages: <br /> ❑ Injury(s) ❑ Fatality(s) ❑ Evacuation Required <br /> Part 13: Notification Checklist <br /> Date and Time Name of Person Receiving Call <br /> DISCHARGE IN ANY AMOUNT <br /> Denisse Vignon Fernandez (209)666-8967 work or <br /> 832 833-5697 cell <br /> DISCHARGE IN AMOUNT EXCEEDING 10 GALLONS AND NOT AFFECTING A WATER BODY OR GROUNDWATER <br /> Tracy Fire Station#97 209 831-6700 or 911 <br /> San Joaquin Environmental Health 209 468-3420 <br /> DISCHARGE IN ANY AMOUNT AND AFFECTING OR THREATENING TO AFFECT A WATER BODY <br /> Tracy Fire Station#97 209 831-6700 or 911 <br /> San Joaquin Environmental Health (209)468-3420 <br /> CUPA <br /> California Office of Emergency Services 800 852-7550 <br /> National Response Center 800 424-8802 <br /> City of Tracy Department of Public Works" 209 831-6300 <br /> Clean Harbors Emergency Response& (800 645-8265)375-5336 <br /> Disaster Recovery Services <br /> 'The POTW should be notified of a discharge only if oil has reached or threatens sewer drains connected to the POTW collection system. <br />