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Spill Notification/Documentation Form <br /> (Spills 10 gallons or greater) a-RAv giLvER+WhES <br /> Part A: Basic S ill Information <br /> Spill Type: Major/Minor [ ] Major [ ] Minor Spill Date: <br /> -Type of Spilled Substance: Spill Time: <br /> Quantity Spilled: Spill Duration: <br /> Facility Name: Revenue Mine Location of Spill: <br /> Owner/ Company Name: Ouray Silver Mines Release to: [ ] Containment [ ] River [ ] Pond [ ] <br /> Inc. Soil Air Ground water Other <br /> Spill ongoing: YES NO [ ] Injuries [ ] Fatalities <br /> Nature of spill and any environmental or health effects: <br /> Measures taken to contain/reduce and/or clean up spill: <br /> PART A: Name/title ofperson(s) reporting spill: <br /> Signature: Date: <br /> Corrective Action/Follow-up: <br /> Report to SUPERVISOR IMMEDIATELY.Form must be filled out and emailed to <br /> environmental(aouraysilvermines.com. A copy must be retained on-site and included with the MCP Plan. <br /> Part B: Notification Checklist (spills greater than 25-gallons) <br /> **To be completed by Environmental, Site/Dept. Mana er** <br /> Spill of greater than 25 gallons of petroleum Name of Person that Received <br /> product or Mill Chemicals above RQ: Notification Date and Time Call <br /> Colorado Department of Public Health and Environment Spill <br /> Hotline <br /> (877)518-5608 <br /> Ouray County Health Department <br /> 970 325-4670 <br /> Colorado Division of Reclamation,Mining and Safety <br /> (303)866-3567 <br /> Spill reaches ground water or surface water: <br /> EPA National Response Center <br /> 800 424-8802 <br /> Part B: Name/Title of person(s) completing notification <br /> Signature: Date: <br />