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Appendix F <br /> Hazardous Waste Contingency Plan <br /> Discharge Notification Form <br /> Part B:Internal Notification Checklist <br /> Release/Fire/Explosion <br /> Date and time Notes <br /> Store Manager <br /> Multi-Store Asset Protection Manager(MSAPM) <br /> See Table 3-2 <br /> Part C:External Initial Notification Checklist <br /> Release, fire, or explosion which could threaten human health, or the environment, outside the facility <br /> Date and Time Name of Person Receiving the <br /> Call/Notes <br /> National Response Center <br /> (800)424-8802 <br /> California Environmental Protection Agency <br /> (800)852-7550 <br /> Part D Written Follow-up Reporting <br /> Within 15 days after an incident that requires implementation of the contingency plan, a written report on the <br /> incident will be submitted to the EPA Regional Administrator and the CalEPA. The report will include: <br /> • Name,address, and telephone number of the Site; <br /> • Name, address, and telephone number of the owner or operator; <br /> • Date,time,and type of incident(e.g.,fire, explosion); <br /> • Name and quantity of material(s)involved; <br /> • The extent of injuries, if any; <br /> • An assessment of actual or potential hazards to human health or the environment, where applicable; <br /> and, <br /> • Estimated quantity and disposition of recovered material that resulted from the incident. <br /> U.S. Environmental Protection Agency <br /> CalEPA Department of Toxic Substances Control <br /> See Table 3-2 <br />