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Spills/1111cit Discharge — Init'I,-.d ftivest.1 'on Form <br /> gati <br /> Name of Investigator <br /> Location of_pill 'discharge;.Lddze5s. andUazzk-;.Closest Intersection): <br /> Count-.- <br /> a'7 as a spill or discharge ob.er,-ed'] <br /> 0 Yes 0211-0 <br /> Was the source of the spill or discharge cLiscol.-eree <br /> 0 Yes 0 NO <br /> Source of the spill:'discharge"" <br /> 13 sewaf!e 0 Wash water :2 Liquid waste El Other(describe) <br /> De.-cribe obsen-ations: (photographs) <br /> Name of Responsible Party(representative) <br /> Phone Number,'Email Address <br /> Address of Responsible Party <br /> Spill,`discharge detai:s(photography) <br /> Attache:additoriaLlifonnatic-n: <br /> Sketch of site Anal,,-acal st=-Ples Phot <br /> Other documentation <br /> Obtain Spilt r' Discharge Investigator's Signature <br /> 177 <br /> R� MAY p C <br /> NIS <br /> Et4,41RONMeN-TAL HEATH <br /> Appendix A—IDDE Source Investigation&Corrective Actions Procedure and Forms <br />