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<br />J <br />~{M{4 <br />i~\ } wl~, <br />e<4: , <br />~~ <br />Form Completed By (Print Name): Sign and Date: <br />P'e,-~-F C.t~ . ~~ f-~ - G a3 d 6 <br />V-•~ii'o~ em(~P(lauJez~•Tose.~was` ~ed.-Fi.,c ~Ib..w (~ (c~~.t(c~ar~~(~~;~~~- o~ -~7..:,`~Ct,...1A~~7.~ip3 l <br />#-h. ~'F gyn. G~( a.Lfi Jtr'~ U,.~~rso~tnp~. d~Srhd..1q fJ.~^o.C a_ 3r~M Y'n.~-. Kiln./. Y~i~~i v~c~/ <br />`Try ; n ~,.} ~o_ o_ e3--~'t n (~ S/~~ <br />((~~ "~ ~ [~ <br />/2-IJ4 _WZ.J C~a3c1~,.- ~,II o^,c uffu/K ~.J~rJ~ :ort'1'~~n~~0 u,.~~/ACX i.K ICs.-r~d_in rv~4n.~-I- aP-E c~1..., d./-~c~-- <br />flC. ((C~~o u~~ ~O~~[[t3-~~Cy4~. i~.~i~y- ~~ CO J~Ld+C',m ;tl/a1r~ tU~C h~ov.rq'~ W~y~ unr~e r~i y' (~o, p~pplfl ~.'IC U~.P-L, <br />'m„ r<-e`J- M e1'~tr; d:~: ~ ~ a,w'4 w n S ~Y S'Fc. c ~c p 11.E t~ r i f-~~t pti+'1 ta -i~~T.',.~. `I1~6L.U `~o a`~ <br />~o r.. e10.'j'Sov. oT (J fv.16 c't-. V <br />,~ .r~~:~ l~ ~~~s <br />~~s, ~"~~~:~ <br />r <br />Y~;~ ~ <br />SpilLNotificatlioa ~Folrm a~ <br />. <br />t <br />. <br />~ <br />S~<y, 11'~ 4 ~.7,. Sit f ~ Ff.~.~ ~ ~ i <br /> <br />Part A: Basic Spill Data <br />Spill Type: Major / o SpiD Date: 6 - „, - - (~ ~ <br />Type of Spilled Substance:-~° ~"~- ~v a~'-" Spill Time: ~j` ~ M <br /> <br />Quantity Spilled: a ~ - a s a~ . Spill Duration: 3 - .S 5 ~Cb n (yC.y <br />Facility Name: United Companies Location of Spill: Ly~,~r.Lr: _.G_r._~~_ _. <br />~ <br />Asphalt Plant /1 46 - 600 i1. <br />?_. ~__Nw~ 33C~~.j3A+,,x,:.,~ <br />/ ---- <br /> Mesh ~o ~ ~ a. <br />Owner /Company Name: Released to: [~ntawment [ ]River <br />United Companies of Mesa County [ ]pond [ ]Soil [ ]Air[ ]Ground Water <br />P. 0. Box 3609 <br />Grand Junction, CO. 81502 []Other <br />store of spill and any envsronmental or health effects: No_ e ~ ~, f~ n M- -a I __e_ . e ei r <br />(.E.n-~-~e.cy-'pile>v.?~'i-ry.ek-driJw_Swrt'-ar~ ~.nrr3 °~ '1'.~e,1Y a-rr.+l <br />p - - <br />. <br />-l j <br />i <br />F <br />li <br />i <br />[ <br />] <br />ur <br />es [ ] <br />ata <br />t <br />es <br /><tq..c1- - t"ecei ~rn c <br /> <br />Part B: Notification Checklist <br />otification Date and Time ame of Person the <br />ecieved Call <br />pillls ~tlty amount of petroleum prods ~ r ~ '~ <br />;~.~,t~ .'`~ ~..~~ :-<, yy~~~,~ ~ ~: <br />" 3. <br />. <br />..., ,.-. ...~ .... .,_ ~ -: w. ,:' <,, r+Tv ''k_. a....... R , <br />_: r.. e iciq i ...~T. r. T+.w .M, .: <br />olonda Department of <br />blic Hesltb and <br />wiromnent <br />(7-a^.3-D~ /;3~PM• /' 1 <br />JEf~. ~H~+ W~~~it~w.S <br />cal Healtb Department <br />'T"t c F Z.. Cu r...'k <br />~ <br />~ <br />(mo)-aa-s-6 <br />i66 6-a3-U6 ~:3oi', t~ <br />~l' <br />ityof Col)brdd / <br />970)-487-37 / C'I2 rK <br />olorado Division of Minerals <br />nd Geology <br />03 86fr3567 . <br />6 - ~ ~ - C3-~ //; 44 A. ~, ~ <br />IV r., ss lea n S ___. <br />03) 231,5465 (~ - ~ j -C~-~ ~; 4S tom. N( o n eS <br />pill reacltes~roland.water ~ arfac'e'w tern' F# <br />4 ~° ~ ~ "~ <br />~ ~' <br /> . <br />. <br />A National Response <br />enter (800) 42~-8802 <br />