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University of the Pacific Spill Prevention, Control, and Countermeasure (SPCC) Plan <br />Stockton, California Aboveground Fuel Storage Tanks <br />APPENDIX H <br />Discharge Notification Form <br />Part A: Discharge Information <br />General information when reporting a spill to outside authorities: <br />Name: Physical Plant, University of the Pacific <br />Address: 1082 Brookside Rd. <br />Stockton, CA 95211 <br />Telephone: (209) 946-2541 <br />Cell (209) 470-2397 <br />Owner/Operator: University of the Pacific <br />3601 Pacific Avenue <br />Stockton, CA 95211 <br />Primary Contact: Mike Ubick, Assistant EHS Director <br />Work: (209) 946-7645 <br />Cell (24 hrs.): (509) 380-7229 <br />Secondary Contact: Lt. Wayne Germann, University Public Safety <br />Work: (209) 946-2357 <br />Cell: (209) 915-1423 <br />Facilities Contact: Emron Qarqat, Construction QC Manager <br />Work: 209-932-3282 <br />Discharge Date and Time: Type of oil: <br />Discovery Date and Time: Quantity released: <br />Quantity released to a storm drain <br />Location/Source: <br />Discharge Duration: <br />Actions taken to stop, remove, and mitigate impacts of the discharge: <br />Affected media: <br />G air G storm water sewer/POTW <br />G water G dike/berm/oil-water separator <br />G soil G other: <br />Notification person: Telephone contact: <br />Business: <br />24-hr: <br />Nature of discharges, environmental/health effects, and damages: <br />Injuries, fatalities or evacuation required? <br />-44-