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Fortune Revenue Silver Mines, Inc. Revenue Mine MCP Plan 2014 <br />Spill /Release Notification Form <br />Part A: Spill/release Information <br />General information when reporting a spill to outside authorities: <br />Name: Fortune Revenue Silver Mines, Inc. <br />Address: 219 10th Avenue <br />Ouray, CO 81427 <br />Telephone: (970) 325 -7256 <br />Owner /Operator: Fortune Revenue Silver Mines, Inc. <br />Primary Contact: John Trujillo, Facility Response Manager <br />Cell: (303) 818 -5563 <br />Type of chemical: <br />Spill /release Date and Time: <br />Quantity released: <br />Discovery Date and Time: <br />Quantity released to a waterbody: <br />Spill /release Duration: <br />Location /Source: <br />Actions taken to stop, remove, and mitigate impacts of the spill /release: <br />Affected media: <br />_ air _ storm water sewer /POTW <br />_ water _ dike /berm /oil -water separator <br />soil other: <br />Notification person: <br />Telephone contact: <br />Business: <br />24-hr: <br />Nature of spill /releases, environmental /health effects, and damages: <br />Injuries, fatalities or evacuation required? <br />Part B: Notification Checklist <br />Date and time <br />Name of person receiving call <br />Spill /release in any amount <br />John Trujillo, Facility Response Manager <br />(970) 325 -7256 <br />Spill /release in amount exceeding reportable quantity and not affecting a waterbody or <br />groundwater <br />Local Fire Department <br />Fire Chief: Adam Kunz <br />(970) 325 -7069 or 911 <br />Colorado Department of Public Health and <br />Environment <br />(877) 518 -5608 <br />26 <br />