Form MMS-1022 Covered Offshore Facility Changes

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

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

Regulation and Enforcement

COVERED OFFSHORE FACILITY CHANGES

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 _____ CHANGES TO LOCATIONS OF COVERED

NUMBER

OFFSHORE FACILITIES OR POTENTIAL WORST CASE OIL-SPILL DISCHARGES LISTED IN THE PREVIOUSLY SUBMITTED APPLICATION FOR CERTIFICATION OF OIL SPILL FINANCIAL RESPONSIBILITY OF _____________.

DATE

____________________________________________ ____________________________________________

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

_____________________________________________________________________ ____________________

TITLE DATE

3. CHANGES TO LOCATIONS OF COVERED OFFSHORE FACILITIES OR POTENTIAL WORST CASE OIL-SPILL DISCHARGES:

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)	TYPE OF CHANGE * (A/D/N)

*A = ADDITION, D = DELETION, AND N = NEW POTENTIAL WORST CASE OIL SPILL

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

BOEMRE FORM MMS-1022 (Mo/Year - Supersedes all previous versions of form MMS-1022 which may not be used). Page 1 of 1