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SpIt1s.,11licit Disc e — Citi Contact Form <br /> pax) <br /> Date•Time Of incident Report <br /> Name of Reporting Fam Phone <br /> Number Email_'add-ens <br /> Address of Reporting Part.- <br /> Is <br /> art:Is anyone hurt'. ( t -, <br /> Descripttcn of spill discharge t7}pe&.amount-color,odor,solid,hgtrid,semi clid;hquid; <br /> rloatables,uotceable conditions): <br /> Location of spill•discharge(Address,Landmarks,Closest Intersection): <br /> Municipality Cot nt,: <br /> Description of discharge source(who is doing it, color of t ehicle,license plate of vehicle,other <br /> descriptors): <br /> Other notes: <br /> -:Oat actions,if arra•,has the reporting party taken".' <br /> 1',ame of C=tv Staff person completm=this form: <br /> `ihen you bare completed the call,you must male the following rewired uorifcatious; <br /> **oub-if there is a fire,explosion,life,health,eni ir•orrzuerrtat threat or a need to evacuate <br /> —Call 911 <br /> Call 911 *** <br /> iw;ame of person notdied Date Time <br /> Call the Engineering Department:(209)941-7.4-40 <br /> Name of person notified Date Tu_e <br /> RECCE I VE ® <br /> MAY 10 2015 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> Appendix A—IDDE Source Investigation&Corrective Actions Procedure and Fornis <br />