Form BSEE-1832 NOTIFICATION OF INCIDENT(S) OF NONCOMPLIANCE

U.S. DEPARTMENT OF THE INTERIOR OMB Control No. 1014-0022

NOTIFICATION OF INCIDENT(S) OF NONCOMPLIANCE You are hereby ordered to correct the identified Incident(s) of Noncompliance (INCs) listed below. You have the right to appeal any INC Notification in accordance with Title 30 CFR part 290. You must file your appeal in the office of the official issuing this Notification. However, the filing of an appeal will not suspend the requirement to comply with this Notification.

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Date

Time (24-Hour Clock)

BSEE Rep. (Print Last Name)

BSEE Office Address

Lease No.

Area and Block

Facility/Rig and Well No.

Complex/Rig ID No.

Lease Operator (Print)

Drill, Prod, P/L Contractor (Print)

Turnkey Company (Print)

Enforcement Action: W -– Warning C -– Component Shut-in S -– Facility Shut-in

PINC No.

Enf. Action

Authority 30 CFR

INC Description and any Special Orders (shut-in of operations, facility, wells, etc.) Potential INC/PINC Guidelines at http://www.bsee.gov/Inspection-and-Enforcement/Inspection-Programs/Inspection-Programs/

Date Corrected

BSEE Representative Signature

Operator Representative Print Last Name Signature

Date

The recipient must report the date each INC was corrected no later than 14 DAYS from the date of issuance.   If you cannot report this within the allotted time, you must obtain a waiver from the appropriate BSEE office.  This process should ensure that company management is aware and acknowledges that INCs were issued on this facility, on this date, but in no way delays any enforcement action taken. The BSEE provides two options for reporting the resolution of the issues identified in the INC: Option 1 – When available, you may use the BSEE-provided web-based “INC Response” system to report INC resolution within the required time period and/or request a time extension waiver.  Only persons registered with BSEE and authorized to represent your company may use this service.  Information about registering and using the web-based system is available at www.bsee.gov. Option 2- If the web-based system is not available, you must insert in the "Date Corrected" column the date each INC was corrected; sign and date a copy of this form; and return it to the BSEE office identified above no later than 14 DAYS from the date of issuance. If a copy cannot be returned within the allotted time, you must obtain an extension from the appropriate BSEE office. Unless specifically ordered otherwise, the operator representative must certify that all component shut-in and facility shut-in INCs identified on this form have been corrected AND the issuing BSEE office has been notified of the corrections before the facility/rig or component may return to operations.

Manager/Supervisor: I certify each Incident of Noncompliance listed above has been corrected on the corresponding date, and I understand that the submission of false statements to the United States is a criminal offense under 18 U.S.C. Section 1001. Print Last Name Signature

Date

Small Business Statement: Your comments are important. The Small Business and Agriculture Regulatory Enforcement Ombudsman and ten Regional Fairness Boards were established to receive comments from small businesses about Federal agency enforcement actions. The Ombudsman will annually evaluate the enforcement activities and rate each agency’s responsiveness to small business. If you wish to comment on the actions of BSEE, call 1-888-REG-FAIR (1-888-734-3247). You may comment to the Small Business Administration without fear of retaliation. Disciplinary action for retaliation by a BSEE employee may include suspension or termination from employment with the Department of the Interior.

Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that BSEE collects this information to ensure that facility management is knowledgeable of the incident of noncompliance issued; corrective action is taken in a reasonable period of time; and for component or facility shut-in enforcement actions, that the identified component or facility is not returned to operation without the prior notice to the appropriate BSEE office. Responses are mandatory (43 U.S.C. 1331 et seq.). No proprietary information is collected. An agency may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a currently valid OMB Control Number. Public reporting burden for this form is estimated to average 3 hours per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You may direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Bureau of Safety and Environmental Enforcement, 45600 Woodland Road, Sterling, VA 20166

BSEE Form BSEE-1832 (Mo/Year - Supersedes all previous editions of this form which may not be used.) Page 1 of 1