Form BOEM-1022 Covered Offshore Facility Changes

U.S. Department of Interior OMB Control No.: _xxxxxxx

Bureau of Ocean Energy Management Expiration Date: xxxxxxx

_{COVERED OFFSHORE FACILITY CHANGES}

CERTIFICATION OF OIL SPILL FINANCIAL RESPONSIBILITY

IN ACCORDANCE WITH THE REQUIREMENTS OF THE OIL POLLUTION ACT OF 1990

(TYPE OR PRINT ALL INFORMATION EXCEPT SIGNATURES)

1. Designated Applicant:

COMPANY LEGAL NAME BOEM COMPANY NUMBER

2. The following list comprises all of changes to locations of covered offshore facilities

NUMBER

or potential worst case oil spill discharges listed in the previously submitted certification of oil spill financial responsibility of _________________________.

DATE

NAME OF AUTHORIZED REPRESENTATIVE SIGNATURE OF AUTHORIZED REPRESENTATIVE

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	RUE OR ROW 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.

FORM BOEM-1022 (Month/Year) PAGE 1 OF 1

Previous Editions are Obsolete.