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State of California—Department of Fish and Wildlife REQUEST FOR DRILL/EXERCISE CREDIT INSTRUCTIONS DFW 1967(Rev. 04/01/14) Page 2 This form needs to be submitted to OSPR pursuant to CCR Title 14, Division 1 Subdivision 4, Chapter 3, Subchapter 3, Section 820.01 (h). It shall be filled in and sent to OSPR when requesting credit for a drill/exercise or actual spill. The CCR states, the"OSPR's Request for Drill/Exercise Credit Form (DFW 1967(04/2014)located at www.dfq.ca.gov/ospr)shall be used to provide this documentation and shall include documentation supporting the objectives tested, such as Site Safety Plan, Incident Action Plan,Waste Management Plan, Communications Plan, etc., as appropriate.The documentation shall be submitted to the Drills and Exercises Program within 60 days after the completion of the drill/exercise. If the information submitted is insufficient,the Plan Holder will be notified and shall have 15 calendar days to send in the completed documentation or the request for credit will be denied." The Request for Credit Form is divided into 4 sections. The top (yellow section)is filled out by all Plan Holders requesting Drill/Exercise credit. The violet section contains the exercise objectives to be used by the Tank Vessels, Nontank Vessels and Marine Facilities.The green section contains the exercise objectives to be used by the Small Marine Fueling Facilities, Mobile Transfer Units and Vessels Carrying Oil as Secondary Cargo.The blue section contains the objectives that may be met during an Equipment Deployment. Include the following information. Name of Facility or Vessel Plan: Name of plan holder conducting the exercise. Plan Number(s):The Contingency Plan number assigned by OSPR example; Facility Plan number E1-11-1111, Vessel Plan number 08-01-1111. OSPR Representative(s): Name or names of OSPR personnel who attended the drill or exercise. Date of Drill/Exercise: Date exercise was conducted. Location of Drill/Exercise:Address where the exercise was held. Scenario Coordinate: If the exercise includes a specific scenario location, what is the latitude/longitude of the spill site? Name of Submitter: Name of individual submitting the Request for Drill/Exercise Credit. Address:Address of the individual submitting the Request for Drill/Exercise Credit Phone: Phone number of submitter. E-mail: E-mail address of the submitter. Type of Drill or Exercise: Tabletop/Functional (an exercise as realistic as possible without deploying resources); Equipment Deployment(actual physical deployment of boom and response vessels); Unannounced(the drill or exercise was not on the calendar);Actual Spill; (see 820.01 (i)5"Actions taken in response to an actual spill in California may be considered for exercise credit."); Other(discussion-based exercises, seminars or workshops which are starting points in exercise complexity. Full-scale exercises, such as PREP exercises are also classified as"other".) Tank Vessels, Nontank Vessels, Marine Facilities—Check the Objectives exercised during tabletop exercises or spills. The listed Objectives are in the California Code of Regulations, Title 14, Division 1 Subdivision 4, Chapter 3, Subchapter 3, Section 820.01. (e). Small Marine Fueling Facilities, Mobile Transfer Units,Vessels Carrying Oil as Secondary Cargo—Check the objectives exercised during tabletop exercises or spills. The listed Objectives are in California Code of Regulations, Title 14, Division 1 Subdivision 4, Chapter 3, Subchapter 3, Section 820.01 (f). Equipment Deployment—Check the Objectives exercised during this drill or spill. The listed Objectives are in California Code of Regulations, Title 14, Division 1 Subdivision 4, Chapter 3, Subchapter 3, Sections 820.01 (g). (Note that all five objectives must be met to receive credit). Authorized Representatives Name: The name of the individual filling out this form. Date: The date this form was filled out.