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State of California-Department of Fish and Wildlife <br /> REQUEST FOR DRILL/EXERCISE CREDIT SAVE PRINT <br /> DFW 1967(Rev. 04/01/14) Page 1 <br /> Name of Facility or Vessel Plan: <br /> Plan Number(s): OSPR Representative(s): <br /> Date of Drill/Exercise: Location of Drill/Exercise: <br /> Address: Scenario Coordinate: Latitude: <br /> Longitude: <br /> Name of Submitter: Address: Phone: <br /> E-mail: <br /> Type of Drill or Exercise <br /> Tabletop/Functional Equipment Deployment Unannounced Actual Spill Other <br /> ❑ ❑1"6 Mos. of yr. 2nd 6 Mos. of yr. ❑ ❑ ❑ <br /> Tank Vessels, Nontank Vessels, Marine Facilities-Check the Objectives exercised during tabletop exercises or spills. <br /> ❑ 1. Notifications ❑ 8.3 Vessel Emergency Services- ❑ 9.3.1 Waste Management <br /> ❑ 2. Staff Mobilization ❑ 8.4 Lightering" ❑ 9.3.2 Applied Response Technology(ART) <br /> ❑ 3. Incident Command System(ICS) ❑ 8.5 Firefighting ❑ 9.4 Documentation <br /> ❑ 4. Unified Command(UC) ❑ 8.6 Shoreline Protection ❑ 9.5 Volunteer Management <br /> ❑ 5. Public Information Officer(PIO) ❑ 8.7 Wildlife Recovery&Rehabilitation ❑ 10. Logistics <br /> ❑ 6. Liaison Officer(LNO) ❑ 8.8 Safety of Responders and Public ❑ 10.1 Communications <br /> ❑ 7. Safety Officer(SOFR) ❑ 9. Planning ❑ 10.2 Personnel Support <br /> ❑ 8. Operations(OPS) ❑ 9.1 Situation Unit ❑ 10.3 *ICP Equipment and Support <br /> ❑ 8.1 Source Control ❑ 9.2 Resource Unit ❑ 11. Finance <br /> ❑ 8.2 Assessment ❑ 9.3 Environmental Unit <br /> *ICP-INCIDENT COMMAND POST **VESSEL APPROPRIATE <br /> Small Marine Fueling Facilities, Mobile Transfer Units, Vessels Carrying Oil as Secondary Cargo-Check the objectives <br /> exercised during tabletop exercises or spills. <br /> ❑ 1. Notifications ❑ 8. Operations ❑ 9.2 Resource Unit <br /> ❑ 2. Staff Mobilization ❑ 8.1 Source Control&Assessment ❑ 9.3 Environmental Unit <br /> ❑ 3. Incident Command System(ICS) ❑ 8.2 Firefighting ❑ 9.4 Waste Management and Disposal <br /> ❑ 4. Unified Command(UC) ❑ 8.3 Containment ❑ 9.5 Documentation <br /> ❑ 5. Public Information ❑ 8.4 Wildlife Recovery&Rehabilitation ❑ 10. Logistics <br /> ❑ 6. Liaison ❑ 9. Planning ❑ 10.1 Personnel&Facility Support <br /> ❑ 7. Safety ❑ 9.1 Situation Unit ❑ 11. Finance <br /> Equipment De to ment <br /> ❑ 1. Notifications ❑ OSRO ❑ NRC ❑ Cal OES ❑ 3. Safety ❑ 5. Communication <br /> ❑ 1 2. Staff Mobilization ❑ 4. Equipment Deployment <br /> Authorized Representatives Name: Date: <br /> NOTE: ONE FORM FOR EACH DRILL CONDUCTED IS REQUIRED. <br /> Please send request via FAX to (916)327-0907 or email to OSPRDRILLSC(DWILDLIFE.CA.GOV <br />