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s <br /> -doc t 8-7 0 <br /> er. 3 <br /> s a,�..a'sa� T "� ���� y� tea:yhi�..��T�, ^��c &"t� '`�r' � •�T.:�? z , � <br /> In the event of a discharge of oil to navigable waters or adjoining shorelines,the following information will be provided to the National <br /> Response <br /> �Cennter�[also se]e�the notification infonnation provided in Section 7 of the Pianr <br /> Ni <br /> .w..,,�. .v ,.'C ►t#@®v[�y„pg`i 7• ¢+ u�p ypgpysg <br /> Discharge/Discovery Date 77 <br /> Time <br /> Facility Name <br /> r <br /> Facility Location (Address/Lat- <br /> Long/Section Township Range) <br /> f� nJ G�9Gf� <br /> Name of reporting individual Telepho e# �® <br /> Type of material discharged Estimated total quantity Gallons/Barrels <br /> discharged <br /> Source of the discharge Media affected <br /> ❑Soil <br /> ❑Water(specify) <br /> ❑Other(specify) <br /> Actions taken <br /> Damage or injuries ❑ No❑Yes(specify) Evacuation needed? <br /> El No®Yes(specify) <br /> Organizations and individuals National Response Center 800-424-8802 Time <br /> contacted <br /> ❑Cleanup contractor(Specify)Time <br /> ❑ Facility personnel(Specify)Time <br /> State gency(Specify)Time <br /> ❑ Other(Specify)Time <br /> Facility Name:� -(,.-� 1d..��~� Page 20 <br /> 9 Tier I Qualified Facility SPCC Plan <br />