PERMFILE101828

• Permit No: M2001090
• IBM Index Class Name: Permit File
• Doc Date: 8/19/2003
• Doc Name: Adequacy Letter
• From: Lafarge West Inc
• To: DMG
• Media Type: D
• Archive: No

Steamboat North Concrete Plant
GL 851
SPCC Plan
ATTACHMENT C
SPILL REPORT FORM
(iJse Paees 1 & 2 of this Plan while filling_out this Sheet)
1 Date:
2 Time:
3 Your name and title:
4 Facility name:
5 Facility address:
6 Facility phone numbers:
~ Type of product
discharged or spilled:
8 Estimate quantity
dischar ed:
9 Cause and source of
discharge:
10 ffec[ed media:
11 ny damages or injuries
as a result:
Emergency actions taken
12 to stop, remove or mitigate
discharge:
13 Names of individuals or
organizations contacted:
14 Person responsible for spill
prevention:
15 Other Remarks:
22