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Appendix H : Discharge Notification Form <br /> In the event of a discharge of oil to navigable waters or adjoining shorelines , the following <br /> information will be provided to the National Response Center (also see the notification <br /> information provided in the Plan) . <br /> Table G 20 Information Provided to the National Response Center in the Event of a <br /> Discharge <br /> Discharge/Discovery Date : Time : <br /> Facility Name : <br /> Facility Location (address/Lat-Long/Section Township Range) : <br /> Name of reporting individual ; Phone Number : <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 National Response Center : (800) 424-8802 <br /> individuals contacted : <br /> Cleanup Contactor (specify) and time : <br /> Facility personnel (specify) and time : <br /> State Agency (specify) and time : <br /> Other (specify) and time : <br /> Chrisp Company <br /> Prepared By William Buckman, Safety Director Page 30 of 31 <br />