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SPILL REPORT (40 CFR 112.7.a.4) <br /> Spill Information <br /> Facility Name <br /> Facility Address/Phone Number <br /> Date and Time of Discharge <br /> Material and Quantity Discharged <br /> Source of the Discharge <br /> Description of Affected Media <br /> Cause of the Discharge <br /> Injuries or Damages Caused by Discharge <br /> Actions being used to stop the Discharge <br /> Was there any Evacuations? (❑ Yes or❑ No) <br /> Name of Person Completing Report <br /> Date Report Completed <br /> Spill Reporting Information <br /> Did oil discharge reach a navigable water? If Yes, contact National Response Center (800) <br /> 424-8802. <br /> Date and Time Contacted <br /> Officer Reported To <br /> Incident Number <br /> Did release meet the conditions as specified in Section 3.113 or on the following page? If Yes, <br /> contact California Office of Emergency Services 800 852-7550. <br /> Date and Time Contacted <br /> Person Reported To <br /> Incident Number <br /> Other Agencies, Individuals, Organizations Contacted <br /> Name Date/Time Phone Number Reason for Contact <br />