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DRAFT Ver. 1-C-doc-4-5-1 0 <br /> ATTACHMENT 4 - Discharge Notification Form <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-28 Information provided to the National Response Center in the Event of a Discharge <br /> Discharge/Discovery Date Time <br /> Facility Name <br /> CALIFORNIA FREIGHT ACAMPO <br /> Facility Location (Address/Lat- <br /> Long/Section 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 I 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 /> Organizations and individuals ❑ National Response Center 800-424-8802 Time <br /> contacted <br /> ❑ Cleanup contractor(Specify) Time <br /> ❑ Facility personnel (Specify)Time <br /> ❑ State Agency(Specify)Time <br /> ❑ Other(Specify)Time <br /> CALIFORNIA FREIGHT ACAMPO <br /> Facility Name: Page 27 Tier 11 Qualified Facility SPCC Plan <br />