Spill Reporting and Remediation Form

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

OMB# 1076-0180

Expires XX-XXXX

NRC#:	Reviewed by:
BIA Tracking Number:	Class of Spill:	Date Scanned:

Spill Reporting and Remediation Form

Operator:
Date of Occurrence:		Time of Occurrence:
Date Report to Osage Agency:		Time Report to Osage Agency:
Reported by:		Phone Number:
Location: Quarter: Section: Township: Range:				Private or Restricted Land (BIA use only)
Latitude:		Longitude:
Lease Name:		Well Name:
Cause of and Extent of Event: Equipment Failure Fire Accident Theft Other
	Volume Discharged (bbls):		Volume Recovered (bbls):		Volume Lost (bbls):
Oil:
Water:
Other:
	Yes		No		Unknown
Surface Water Impacted?
Impact to vegetation or soils
Fish and/or Wildlife
Livestock Impacted?
If “Yes” is checked above, please describe:
What did you do to control the spill event?

NRC#:	Reviewed by:
BIA Tracking Number:	Class of Spill:	Date Scanned:

How did you clean up/remediate the spill are and what dates did the activities occur?

How do you plan to restore vegetation to the site?

What actions did you take to prevent this occurring again?

I certify that I have corrected all violations and lease deficiencies related to the above described lease, as listed in Notices of Deficiency and/or Orders of the Superintendent served upon me and that the lease is now in compliance with the regulations found at 25 CFR Part 226 in respect to the spill incident. I have attached photos and other documentation necessary to show that that the work has in fact been complete. I have sent a copy of this completed form to the surface owner.

I acknowledge that, failure to remediate the above location may result in the assessment of fines and penalties by the BIA, pursuant to 25 CFR 226.42 and 25 CFR 226.43(j), or that other enforcement action may be taken.

Name (Printed)

Company’s Authorized Representative

Signature

Company’s Authorized Representative

Date

Osage Agency Form

Revised: July 14, 2016

Osage Agency Form

Revised: July 14, 2016

Osage Agency Form

Revised: July 14, 2016

Osage Agency Form

Revised: July 14, 2016

Osage Agency Form

Revised: July 14, 2016

Osage Agency Form

Revised: July 14, 2016

Osage Agency Form

Revised: July 14, 2016

Osage Agency Form

Revised: July 14, 2016

Osage Agency Form

Revised: July 14, 2016

Osage Agency Form

Revised: July 14, 2016

Osage Agency Form

Revised: July 14, 2016

Osage Agency Form

Revised: July 14, 2016

Osage Agency Form

Revised: July 14, 2016