2012-02-28_REVISION - M1980244 (82)

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6.1 Information for External Agency Reporting 1. NAME AND TELEPHONE NUMBER OF PERSON MAKING REPORT: DATE CALLED: AGENCY CALLED WHOM CALLED: TIME CALLED 2. 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 & 105° 09'27 "W Legal Location: (Township, Range, Section, % section): NW1 /4, Sec 31, T15S, R69W 3. COUNTY WHERE SPILL OCCURRED: TELLER 4. LOCATION WHERE SPILL OCCURRED (ADDRESS OR OTHER LOCATION INFORMATION): (Relate to Mining District, State or County Roads, Township, Section and Range 5. 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: 6. 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): 11. 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: Spill Response Plan EMS: AGANA/CCV G:\EMS \Plans \Emergency Response Plans \SRP Plan\SRP Plan.doc Printed Copies are Uncontrolled August 17, 2010 Doc. # E -006 Revision 05 36