Form MMS-1017 Designation of Applicant

U.S. Department of the Interior OMB Control No. 1010-0106

Bureau of Ocean Energy Management, OMB Approval Expires: xx/xx/xxxx

Regulation and Enforcement

DESIGNATION OF APPLICANT

OIL POLLUTION ACT OF 1990 APPLICATION FOR CERTIFICATION OF OIL SPILL FINANCIAL RESPONSIBILITY

(TYPE OF PRINT ALL INFORMATION EXCEPT SIGNATURES)

1. DESIGNATED APPLICANT: ______________________________________________________ ___________________________

COMPANY LEGAL NAME BOEMRE COMPANY NUMBER

__________________________________________________________________________________________________________ ___________________________

ADDRESS BOEMRE COMPANY REGION

___________________________________________________________________________________________________________________________________________

CITY STATE ZIP CODE

2. RESPONSIBLE PARTY: ___________________________________________________ ___________________________

COMPANY LEGAL NAME BOEMRE COMPANY NUMBER

__________________________________________________________________________________________________________ ___________________________

ADDRESS BOEMRE COMPANY REGION

___________________________________________________________________________________________________________________________________________

CITY STATE ZIP CODE

__________________________________________________________________ __________________________________________________________________

CONTACT PERSON CONTACT PERSON’S TITLE

( )___________________________ ( )___________________________ ___________________________

AREA CODE and TELEPHONE NUMBER AREA CODE and FAX NUMBER E-MAIL ADDRESS

3. AS AN OFFICER OR DESIGNATED AGENT OF THE RESPONSIBLE PARTY, I NAME THE DESIGNATED APPLICANT IDENTIFIED ABOVE TO ACT FOR THE RESPONSIBLE PARTY FOR THE CERTIFICATION OF OIL SPILL FINANCIAL RESPONSIBILITY IN ACCORDANCE WITH THE OIL POLLUTION ACT OF 1990 AND 30 CFR 253 FOR THE LOCATIONS OF COVERED OFFSHORE FACILITIES DESCRIBED HEREIN. THE RESPONSIBLE PARTY WILL ENSURE THAT THE DESIGNATED APPLICANT ESTABLISHES AND MAINTAINS OIL SPILL FINANCIAL RESPONSIBILITY FOR THESE SPECIFIED LOCATIONS IN ACCORDANCE WITH 30 CFR 253 AND IN THE AMOUNTS SPECIFIED BY THE BUREAU OF OCEAN ENERGY MANAGEMENT, REGULATION AND ENFORCEMENT. THE RESPONSIBLE PARTY CERTIFIES THAT IT WILL BE JOINTLY, SEVERALLY, AND STRICTLY LIABLE, TOGETHER WITH THE OTHER RESPONSIBLE PARTIES, FOR ALL OIL SPILL REMOVAL COSTS AND DAMAGES IN ACCORDANCE WITH THE OIL POLLUTION ACT OF 1990.

THIS DESIGNATION IS EFFECTIVE BEGINNING ON ________________________________. THE RESPONSIBLE

DATE

PARTY WILL NOTIFY THE OIL SPILL FINANCIAL RESPONSIBILITY PROGRAM IN WRITING WHEN THIS DESIGNATION IS CANCELED.

___________________________________________________________________ ___________________________

NAME SIGNATURE

________________________________________________________________________________________________ _______________________________________

TITLE DATE

4. THE RESPONSIBLE PARTY’S U.S. AGENT FOR SERVICE OF PROCESS IS: ___________________________

NAME

__________________________________________________________________________________________________________ _____________________

ADDRESS BOEMRE COMPANY NUMBER

____________________________________________________________________________________________________________________________________________

CITY STATE ZIP CODE

( )___________________________ ( )___________________________ ____________________________

AREA CODE and TELEPHONE NUMBER AREA CODE and FAX NUMBER E-MAIL ADDRESS

If the designated U.S. Agent for Service of Process cannot be served due to death, disability, or unavailability, the Director, U.S. Coast Guard National Pollution Funds Center, is the U.S. Agent for Service of Process.

BOEMRE FORM MMS-1017 (Mo/Year – Supersedes all previous versions of form MMS-1017 which may not be used). Page 1 of 2

5. LOCATIONS OF COVERED OFFSHORE FACILITIES:

STATE OR OCS REGION	LEASE NUMBER	ALIQUOT PORTION (If applicable)	AREA NAME	BLOCK NUMBER	PERMIT NUMBER	RIGHT OF USE AND EASEMENT NUMBER	PIPELINE SEGMENT NUMBER

IF ADDITIONAL SPACE IS REQUIRED, ADDITIONAL COPIES OF THIS PAGE MAY BE ATTACHED AS CONTINUATION PAGES.

BOEMRE FORM MMS-1017 (Mo/Year – Supersedes all previous versions of form MMS-1017 which may not be used). Page 2 of 2