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ATTACHMENT 4 – Discharge Notification Form<br />
Ver. 1-E-doc-3-18-10<br />
In the event <strong>of</strong> a discharge <strong>of</strong> 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 <strong>of</strong> the Plan]:<br />
Table G-20 Information provided to the National Response Center in the Event <strong>of</strong> a Discharge<br />
Discharge/Discovery Date<br />
Time<br />
Facility Name<br />
Facility Location (Address/Lat-<br />
Long/Section Township Range)<br />
Name <strong>of</strong> reporting individual<br />
Type <strong>of</strong> material discharged<br />
Telephone #<br />
Estimated total quantity<br />
discharged<br />
Source <strong>of</strong> the discharge Media affected Soil<br />
Actions taken<br />
Damage or injuries<br />
Organizations and individuals<br />
contacted<br />
Facility Name:<br />
No Yes (specify)<br />
Evacuation needed?<br />
National Response Center 800-424-8802 Time<br />
<strong>Clean</strong>up contractor (Specify) Time<br />
Facility personnel (Specify) Time<br />
State Agency (Specify) Time<br />
Other (Specify) Time<br />
Gallons/Barrels<br />
Water (specify)<br />
Other (specify)<br />
No Yes (specify)<br />
Page 19 Tier I Qualified Facility SPCC Plan
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