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<br /> <br />Spill/Release Notification Form <br /> Part A: Spill/release Information <br />General information when reporting a spill to outside authorities: <br />Name: Grand Island Resources, Inc. <br />Address: 12567 W Cedar Dr, Lakewood, CO 80228 <br /> <br />Telephone: 516 582-0833 <br />Owner/Operator: Grand Island Resources, Inc. <br />Primary Contact: Rich Mittasch, Facility Response Manager <br />Cell: 516 582-0833 <br /> <br />Type of chemical: Spill/release Date and Time: <br />Quantity released: Discovery Date and Time: <br />Quantity released to a waterbody: Spill/release Duration: <br />Location/Source: <br /> <br />Actions taken to stop, remove, and mitigate impacts of the spill/release: <br /> <br /> <br />Affected media: <br />___ air <br />___ water <br />___ soil <br /> <br />___ storm water sewer/POTW <br />___ dike/berm/oil-water separator <br />___ other: _________________________ <br />Notification person: Telephone contact: <br />Business: <br />24-hr: <br />Nature of spill/releases, environmental/health effects, and damages: <br /> <br /> <br /> <br />Injuries, fatalities or evacuation required? <br />