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CLIIvLa,Y ~fOLYSDENLtii CON~.~`Il' - HENDERSON ~IINE A,~fD ivIILL <br />SPILL AND RELEASE 12vT'ORMATION SHEET <br />The information below is privileged and confrdential and has been developed at the direction of cotozsel to aid in <br />providing legal aavice. Thrs form should be submined to the Cyprus Amax Law Department. <br />tE of this Report: Date and Time of Spill/ Release: <br />Date and Time of Notification to Environmental Department <br />Name of Person Notified: <br />Type and Concentration of Material Spilled/Released: <br />Estimate of Qaantity Spr7led/Released (in gallons and pounds): <br />Loratioa of Spill/Release: (use back or additional sheeb) <br />Dncription of Iacideat: (Iaclade cause of spill/release, it (mown; and where and to what spill/release was spilled or ' <br />released to -paved road, son, etc) (use back or additional sheeb) <br />Response actions taken: (use back or additional sheen) <br />Name: (print) Signature: <br />~_ <br />?O BE COMPLETED BYTEE.ENYFRONMENT.4L.DEPARTKE'vT ::, <::,:. ;' ::::.: :..::.::..::.:::::::.:<:':>;:; <br />~ Did the material spilled/released contain a listed chemical? Yes No <br />Chemical: 1. CERCLA SARA RQ _ <br />2. CERCLA SARA RQ _ <br />3. CERCLA SARA RQ _ <br />4. CERCLA SAR4 RQ _ <br />Did the material spilled enter waters of the united States: Yes No <br />If yes, describe fully: <br />Is the spill/release reportable as required in Section 8 of the EMPM? Yes No <br />Base for determination: <br />If reportable: <br />Name of penon contacted and agency: <br />Date, time and report number: <br />entlve Actions Taken: (use back or additional sheets) <br />Name: (print) Signature: <br />