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APPENDIX 6: SPILL REPORTING FORM <br /> Part A: Basic Spill Data <br /> Type of Spilled Substance: Notification Person: <br /> Quantity Released: Spill Date and Time: <br /> Location of Spill: Discovery Date and Time: <br /> Spill Duration: <br /> Plant Name & Location: Release to: []air [] water [] ocean <br /> Gencor Portable Asphalt Plant [] well [] soil [] sewer <br /> Current Plant Location: [] containment <br /> []other <br /> Owner/Company Name: Telephone: <br /> A & S Construction Co. (719) 275-3264 main <br /> P.O. Box 566 (attn: Denise Gonzales or Phil Rieg) <br /> Canon City, CO 81215 <br /> Nature of spill and any environmental or health effects: <br /> []Injuries [] Fatalities <br /> Part B: Notification Checklist <br /> Spill Type Notification Date and Name of Person that <br /> Time Received Call <br /> Spill reaches groundwater or surface water: <br /> EPA National Response Center (800) 424-8802 <br /> Colorado Dept. of Public Health and <br /> Environment (Water Quality Control Division) <br /> (303) 692-3500 <br /> Division of Minerals and Geology (if plant is <br /> located within a permitted mine site) <br /> (303) 866-3567 <br /> Portable Gencor Asphalt Plant Page 21 <br /> SPCC Plan August 31, 2005 <br />