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• <br />• <br />11 <br />SPILL REPORT FORM <br />INITIAL INFORMATION.- <br />Date: Time Reported ( ) AM <br />( PM P ime Occurred ( ) AM <br />( PM <br />Individual Reporting: (Your Name) <br />Phone # Company Name: <br />Location of Spill: Address: <br />Product Spilled Estimated Amount County, City, State, Zip <br />Source & Cause of Incident: <br />Person Reported To: Weather/Stream Conditions: <br />Severity of Spill: Meeting Federal Obligations to Report? <br />CURRENT CONDITIONS <br />(Include Containment and/or Clean-up Efforts) <br />NOTIFICATION <br />Persons and/or <br />Agencies Notified Phone <br />Number Date and Time <br />Notified Written Follow-up Report <br />Required es/no <br /> <br /> <br />