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<br />This form must be submitted to the Facility Manager. A copy must be retained on-site and included with <br />the MCP Plan. <br /> <br />Spill Notification/Documentation Form <br />Part A: Basic Spill Data <br />Spill Type: Major / Minor [ ] Major [ ] Minor Spill Date: <br />Type of Spilled Substance: Spill Time: <br />Quantity Spilled: Spill Duration: <br />Facility Name: Cross Gold Mine Location of Spill: <br />Owner / Company Name: Grand Island <br />Resources <br />Release to : <br />[ ] Containment <br />[ ] River [ ] Pond [ ] Soil [ ] Air <br />[ ] Groundwater [ ] Other <br />Nature of spill and any environmental or health <br />effects: <br />[ ] Injuries [ ] Fatality <br />*Complete Part B if the spill is greater than reportable quantity <br />Part B: Notification <br />Checklist <br /> <br />Spill of greater than <br />reportable quantity of <br />chemical: <br />Notification Date and Time Name of Person <br />the Received Call <br /> <br />Colorado Department of Public Health and Environment <br />(877) 518-5608 <br />Boulder County Health Department <br />(303) 441-1100 <br />Colorado Division of Reclamation, Mining and Safety <br /> <br />(303) 866-3567 <br /> <br /> MSHA (303) 231-5465 <br />Spill reaches ground water or surface water: <br />EPA National Response Center (800) 424-8802 <br /> <br />Form Completed By (Print Name): Sign and Date: