Form Ogb-24 - Operator'S Certificate Of Compliance For Operations Involving Hydrogen Sulfide

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STATE OIL AND GAS BOARD OF ALABAMA

OGB-24

Operator’s Certificate of Compliance for

Operations Involving Hydrogen Sulfide

Form OGB-24, Rev. 07/13

___________________________________________

____________________________________________

(File in triplicate)

Permit Number (if applicable)

API Number (if applicable)

New

Amended

Annual

Name of operator ____________________________________________________________________________________________________

Address __________________________________________ City ___________________________ State ___________ Zip ____________

1. Facility name

2. County

(give footage from nearest section or offshore tract lines)

Section-Township-Range or Tract

Facility

Location*

Latitude

Longitude

▪

(NAD27)

(surface)

4. Field (If wildcat, so state)

5. Operation type

6. H

S source

7. H

S content (mole fraction)

8. Max. escape vol.

SCF/day

9. Radius of exposure (ROE)

feet

10. Public area within ½ mi.

Yes

RULE REQUIREMENTS

For the above described operation the

Safety Program (2)

Monitor & Alarms (4b)

Training Requirements (5)

following requirements (paragraphs) are

applicable and have been or will be

Equip. & Materials (3)

Wind Direction Equip. (4c)

Personnel Safety Equip. (6)

implemented in accordance with Rule 400-

Warning Signs (4a)

Danger Signals (4d)

Contingency Plan (7)

1-9.-02 or 400-2-8-.04, whichever is

applicable.

AMENDED CERTIFICATE

Reason(s)

Facility modification

Public infringement

ROE change

Requirement change

Other

Explain:

Contingency Plan

Required

Yes

Location of Plan ___________________________________________

Amendments required

Yes

Local Authorities Notified

Yes

Person to contact

Phone number

regarding this form

Fax number

E-mail address

Remarks:

* Omit for gathering lines

The undersigned certifies that the above operator has complied, or will comply, with all applicable requirements of Rule 400-1-9-.02 or 400-2-8-

.04, whichever is applicable of the State Oil and Gas Board of Alabama Administrative Code, as last amended, and the undersigned further

certifies that the conservation laws of the State of Alabama and all rules, regulations, and orders of the Board have been complied with in

respect to the area covered by this certificate.

________

___________________________________________________

Executed this the _______ day of __________

, 20 __

Signature

________________________________________

Before me, the undersigned authority, on this day personally appeared

known to me to be the person

whose name is subscribed to the above instrument, who being by me duly sworn on oath states that he/she is duly authorized to make the above report and that

he/she has knowledge of the facts stated therein, and that said report is true and correct.

_______

____________________

_________

Subscribed and sworn to before me this

day of

, 20

_____________________________________

_____________________

Notary Public in and for

SEAL

____________________