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Ver . 1 -E-doc-3-18- 10 <br /> 7777777777- 7, -- , <br /> ATTACHMENT '4 btscharge , 0 Ilca fort form <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 Center [also see the notification information provided in Section 7 of the Plan) : <br /> ;: #�1 =2Q !n#grim tio> p�t5v'i€ted <br /> to i.$se Nairl r�all ReS 4r se '-enter Ir =f he ve t cif a D"s c a ` <br /> Discharge/ Discovery Date Time <br /> o . e •f' it. r <br /> Facility Name <br /> MAR 02 2016 <br /> Facility Location (Address/Lat. ' <br /> Long/Section Township Range ) E NV I R 0 A <br /> NTAL <br /> Name of reporting individual Telephone # <br /> Type of material discharged Estimated total quantity Gallons/Barrels <br /> discharged <br /> Source of the discharge Media affected ❑ Soil <br /> ❑ Water (specify) <br /> ❑ Other (specify) <br /> Actions taken <br /> Damage or injuries [:] No ❑ Yes (specify ) Evacuation needed ? ❑ No ❑ Yes (specify) <br /> Organizations and individuals ❑ National Response Center 800424-8802 Time <br /> contacted <br /> ❑ Cleanup contractor ( Specify ) Time <br /> ❑ Facility personnel ( Specify) Time <br /> ❑ State Agency ( Specify ) Time <br /> ❑ Other ( Specify ) Time <br /> Facility Name: J . M . Equipment Co . ; Inc. Bus Fac. Page 22 Tier I Qualified Facility SPCC Plan <br />