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CENTERVILLE-OSTERVILLE-MARSTONS MILLS FIRE DISTRICT
IRECEIVED 1875 ROUTE 28
CENTERVILLE, MA 02632
J U N 3 2002 (508)790-2580/FAx#(508)790-2385
TOWN OF
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FIRE DEPARTMENT: YES( )XO( ) DATE: TIME:
NATIONAL RESPONSE CEIWER YES(,}/NO( ) DATE: TIME:
DEPT.OF ENVIRONMENTAL PROTECTION YES( ) NO( ,) ATE: TIME:_,,,,„_,_
OIL SPILL COORDINATOR: YES( ) NO( ) DATE: TIME:
TOWN BOARD OF HEALTH: YES( ) NO( ) DATE: TIME:
TOWN HARBORMASTER: YES(j/NO( DATE:TIME:
OTHER AGENCIES:
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CENTERVILLE-OSTERVILLE-MARSTONS MILLS FIRE DISTRICT
1875 ROUTE 28
CENTERVILLE, MA 02632
(508)790-2380/FAX#(508)790-2385
OILIHAZARDOUS MATERIAL RELEASE FORM
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LOCATION:
ADDRESS OF RELEASE: 12,-L
DATE OF RELEASE: " Z— ` Q_t
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CORRECTIVE ACTION TAKEN B RESPONSIBLE PART .
NOTIFICATIONS:
FIRE DEPARTMENT: YES(i, NO( ) D TE: TIME:
NATIONAL RESPONSE CENTER YES(4NO( ) DATE: TIME:
DEPT.OF ENVIRONMENTAL PROTECTION Y ( ) NO( ATE: TIME:
OIL SPILL COORDINATOR: YES( ) NO( DATE: TIME:
TOWN BOARD OF HEALTH: YES( ),NO( } DATE:_TIME:
TOWN HARBORMASTER: YES(t/f NO( } DATE:_______TIME:
OTHER AGENCIES:
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COMMENTS:
REPORTED BY:G�' - ._1 /^r�..)_: • t/ DATE:
WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH
C-O-MM FORM#58