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Fortune Revenue Silver Mines Inc. <br />Revenue Mine MCP Plan 2014 <br />Spill Notification/Documentation Form <br />Part A: Basic Spill Data <br />Spill Type: Major / Minor [ ] Major [ ] Minor <br />Spill Date: <br />Type of Spilled Substance: <br />Spill Time: <br />Quantity Spilled: <br />Spill Duration: <br />Facility Name: Revenue Mine <br />Location of Spill: <br />Owner / Company Name: Fortune Revenue <br />Silver Mines, Inc. <br />Release to : [ ] Containment [ ] River [ ] Pond [ ] Soil [ ] Air <br />[ ] Ground water [ ] Other <br />Nature of spill and any environmental or health <br />effects: <br />[ ] Injuries [ ] Fatality <br />*Complete Part B if the spill is geater than reportable quantity <br />Part B: Notification Checklist <br />Spill of greater than <br />reportable quantity of <br />chemical: <br />Notification Date and Time <br />Name of Person the Received Call <br />Colorado Department of Public <br />Health and Environment <br />87 518 -5608 <br />Ouray County Health <br />Department <br />(970) 3254670 <br />Colorado ivision o <br />Reclamation, Mining and Safety <br />(303) 866 -3567 <br />MSHA (303) 231 -5465 <br />Spill reaches ground water or surface water: <br />EPA National Response <br />Center (800) 424 -8802 <br />Form Completed By (Print Name): <br />Sign and Date: <br />This form must be submitted to the Facility Manager. A copy must be retained on -site and included <br />with the MCP Plan. <br />25 <br />