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Appendix F <br />Hazardous Waste Contingency Plan <br />Discharge Notification Form <br />Part 8 Internal Notification Checklist <br />Release / Fire / Explosion <br />Date and time <br />Notes <br />Store Manager <br />Multi -Store Asset Protection Manager (MSAPM) <br />See Table 3-2 <br />Part C P External Initial Notification Checklist <br />Release, fire, or explosion which could threaten human health, or the environment, outside the facility <br />Date and Time <br />Name of Person Receiving the <br />Call/ Notes <br />National Response Center <br />(800)424-8802 <br />California Environmental Protection Agency <br />(800)852-7550 <br />Part D Written Follow-up Reporting <br />Within 15 days after an incident that requires implementation of the contingency plan, a written report on the <br />incident will be submitted to the EPA Regional Administrator and the CalEPA. The report will include: <br />• Name, address, and telephone number of the Site; <br />• Name, address, and telephone number of the owner or operator; <br />• Date, time, and type of incident (e.g., fire, explosion); <br />• Name and quantity of material(s) involved; <br />• The extent of injuries, if any; <br />• An assessment of actual or potential hazards to human health or the environment, where applicable; <br />and, <br />• Estimated quantity and disposition of recovered material that resulted from the incident. <br />U.S. Environmental Protection Agency <br />CalEPA Department of Toxic Substances Control <br />See Table 3-2 <br />