Form Ogb-27 - Notification Of Fire, Spill, Leak, Or Blow Out Incident Report - State Oil And Gas Board Of Alabama
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1STATE OIL AND GAS BOARD OF ALABAMA
OGB-27
Notification of Fire, Spill, Leak, or Blow Out
Incident Report
01
Form OGB-27, Rev. 07/13
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___________________________________________
____________________________________________
(File in duplicate)
Permit Number (if applicable)
API Number (if applicable)
Fire
Spill
Leak
Blow Out
Name of operator __________________________________________________________________ Date _____________________________
Address _________________________________________ City ___________________________ State ____________ Zip ____________
1. Facility name
2. County
(give footage from nearest section or offshore tract lines)
Section-Township-Range or Tract
Facility
3.
Location*
Latitude
Longitude
▪
▪
(NAD27)
(NAD27)
(surface)
3. Field (If wildcat, so state)
NOTIFICATION OF INCIDENT
OGB Staff Member Notified: __________________________________________________ Reporting Date: ____________________________
Time: ___________________ Reported By (Company Representative): _________________________________________________________
When Did Incident Occur? Date: _______________________________ Time: ____________________ AM
PM
Did incident cause injury or death?
Yes
No
If Yes, list names and indicate whether injury or death occurred: ________________________________________________________________
___________________________________________________________________________________________________________________
Material spilled: ______________________________________________________________________________________________________
Estimated volume of spill or leak: ________________________________________________________________________________________
Material contained on location?
Yes
No
If no, describe affected area below and on the reverse side of this form, draw a plat showing area affected by material.
Description of affected area: ____________________________________________________________________________________________
___________________________________________________________________________________________________________________
Material entered a stream, creek, swamp, or and water area?
Yes
No
If yes, identify other state and federal agencies that were notified:
Agency: ___________________________________________________ Contact Person: ___________________________________________
Agency: ___________________________________________________ Contact Person: ___________________________________________
CAUSE AND ACTIONS
Circumstances causing the incident: ______________________________________________________________________________________
Measures taken to control fire, spill, leak or blow out: _________________________________________________________________________
Measures taken to clean up: ____________________________________________________________________________________________
Measures taken to prevent reoccurrence of this incident: ______________________________________________________________________
Date that cleanup operations completed (if completed): _______________________________________________________________________
Remarks:
* Omit for gathering lines
I am authorized to make the above report and have knowledge of the facts stated therein. I certify that said report is true and correct.
____________________________________________________________
_______________________________________
Signature of Operator’s Agent
Date
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