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Discharge Notification Form <br /> Dameron Hospital —A Non-Profit Corporation <br /> 525 W. Acacia Street <br /> Stockton, CA 95203 <br /> Description of Discharg <br /> Date/time Release date: Discovery date: <br /> Release time: Discovery time: <br /> Duration: <br /> Reporting Individual Name: <br /> Tel.M <br /> Location of discharge Latitude: Description: <br /> Longitude: <br /> Equipment source ❑ piping Description: <br /> ❑flowline Equipment ID: <br /> ❑ well <br /> ❑ unknown <br /> ❑ stock,flare <br /> Product ❑ crude oil *Describe other: <br /> ❑ saltwater <br /> ❑ other* <br /> Appearance and <br /> description <br /> Environmental conditions Wind direction: Rainfall: <br /> Wind speed: Current: <br /> Impacts <br /> Quantity Released: Recovered: <br /> Receiving medium ❑ water** ❑ Release confined to company property. <br /> ❑ land ❑ Release outside company property. <br /> ❑ other(describe): ** If water, indicate extent and body of water: <br /> Describe circumstances <br /> of the release <br /> Assessment of impacts <br /> and remedial actions <br /> Disposal method for <br /> recovered material <br /> Action taken to prevent <br /> incident from reoccurring <br /> Safety issues ❑ Injuries <br /> ❑ Fatalities <br /> ❑ Evacuation <br />