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

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to identify and monitor lease operations and protection of trust asset. Your response is voluntary and we will not share the results publicly. We 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. OMB has reviewed and approved this survey and assigned OMB Control Number 1076-0180, which expires ##/##/####.

Estimated Burden Statement: We estimate the form will take you 28 hours to complete, including time to read instructions, gather information, and complete and submit the form. You may submit comments on any aspect of this information collection to the Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S. Department of the Interior, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.

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