REV04422

• Permit No: M1980244
• IBM Index Class Name: Revision
• Doc Date: 5/5/2003
• Doc Name: Emergency Response Plan pgs 29-45
• From: CC&V
• To: DMG
• Media Type: D
• Archive: No

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Information for External Agency Reporting
NAME AND TELEPHONE NUMBER OF PERSON MAKING REPORT:
DATE CALLED: AGENCY CALLED
WHOM CALLED: TIME CALLED
NAME AND MAILING ADDRESS OF COMPANY FOR WHOM REPORT IS BEING MADE:
Physical Address: 1280 HWY 67 between Victor and Cripple Creek, Teller County, Colorado 80860
Mailing Address; P.O. BOX 191, {100 North Third St), VICTOR, COLORADO 80860
Location Coordinates: Latitude and Longitude: Security Office - 38° 43'37"N 8 105° 09'27"W
Legal Location: {Township, Range, Section,'/a section): NW7/4, Sec 31, T15S, R69W
COUNTY WHERE SPILL OCCURRED: TELLER
LOCATION WHERE SPILL OCCURRED (ADDRESS OR OTHER LOCATION INFORMATION): (Relate to
Mining District, State or County Roads, Township, Section and Range
DATE AND TIME OF INCIDENT: (Time of start of release, times of control measures)
Time of Spill:
Time Spill Stopped or Contained:
Time Cleanup Started:
Time Cleanup Finished:
NAME OF MATERIALS SPILLED (CHEMICAL NAME IF POSSIBLE):
7. QUANTITY OF MATERIAL SPILLED (The accuracy of this information is important. Indicate whether the
quantity is estimated or measured:
8. SOURCE AND CAUSE OF SPILL:
9. STATEMENT OF WHERE SPILL OCCURRED (IF INTO ANY STREAMS OR WATERWAYS, THE NAMES
OF SUCH STREAMS OR WATERWAYS) (Use USGS Topographic Maps if possible) (If material did not
reach a drainage, especially not Arequa Gulch, Squaw Gulch, Bateman Creek, or Grassy Valley, it likely did
not enter a 'stream'.
10. DESCRIPTIONS OF ANY INJURIES, FATALITIES, EVACUATIONS OR PROPERTY DAMAGES (This must be "
cleared with the Safety Department):
17. DESCRIPTION OF REMEDIAL ACTIONS OR CLEANUP TAKEN AND/OR TO BE TAKEN:
12. NAMES OF OTHER AGENCIES THAT HAVE BEEN OR ARE TO BE NOTIFIED:
13. INCIDENT NUMBER PROVIDED BY AGENCY:
14. WRITTEN REPORTS REQUIRED BY AGENCY
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