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Actions taken to stop, remove, and mitigate impacts of the discharge: <br /> Affected media: <br /> ❑ air ❑ storm water sewer/POTW <br /> ❑water ❑ dike/berm/oil-water separator <br /> ❑ soil ❑ other: <br /> Notification <br /> Person Notified: Agency/Department: <br /> Nature of discharges, environmental/health effects and damages (if any): <br /> Injuries, fatalities or evacuation required? <br /> Date: Time: Name: <br />