Form MMS-1021 Covered Offshore Facilities

30 CFR 253, Oil Spill Financial Responsibility for Offshore Facilities

Form 1021 exp 12-13

40; 41 - Form MMS-1021- Covered Offshore Facilities

OMB: 1010-0106

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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

COVERED OFFSHORE FACILITIES


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

(TYPE OR PRINT ALL INFORMATION EXCEPT SIGNATURES)



1. DESIGNATED APPLICANT: ______________________________________________________ ___________________________

COMPANY LEGAL NAME BOEMRE COMPANY NUMBER


2. THE FOLLOWING LIST COMPRISES PART OR ALL OF _____ LOCATIONS OF COVERED OFFSHORE FACILITIES

NUMBER

TO BE COVERED BY MY APPLICATION FOR CERTIFICATION OF OIL SPILL FINANCIAL RESPONSIBILITY.


____________________________________________ ____________________________________________

NAME OF CORPORATE OFFICER OR DESIGNATED AGENT SIGNATURE OF CORPORATE OFFICER OR DESIGNATED AGENT


_____________________________________________________________________ ____________________

TITLE DATE


3. 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

POTENTIAL WORST CASE OIL-SPILL DISCHARGE (In Barrels)



























































































































































































































BOEMRE FORM MMS-1021 (Mo/Year – Supersedes all previous versions of form MMS-1021 which may not be used). Page 1 of 2



3. LOCATIONS OF COVERED OFFSHORE FACILITIES (continued):


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

POTENTIAL WORST CASE OIL-SPILL DISCHARGE (In Barrels)



















































































































































































































































































































































































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


BOEMRE FORM MMS-1021 (Mo/Year – Supersedes all previous versions of form MMS-1021 which may not be used). Page 2 of 2


File Typeapplication/msword
File TitleMINERALS MANAGEMENT SERVICE
AuthorAlexis London
Last Modified Byblundonc
File Modified2010-08-30
File Created2010-08-30

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