Form Ogb-12 - Operator'S Certificate Of Compliance And Authorization To Transport Oil, Gas, Or Condensate From Well

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STATE OIL AND GAS BOARD OF ALABAMA

OGB-12

Operator’s Certificate of Compliance and Authorization

to Transport Oil, Gas, or Condensate from Well

Form OGB-12, Rev. 07/13

__________________________________________

____________________________________________

(File in triplicate)

Permit Number

API Number

(If multiple wells, list in remarks or on attachment)

Name of Operator ____________________________________________________________________________________________________

Address ________________________________________ City ___________________________ State ____________ Zip _____________

1. Well name and number

2. County

(give footage from nearest section or offshore tract lines)

Section-Township-Range or Tract

3. Well Location

(surface)

4. Field (if wildcat, so state)

5. The above named operator hereby authorizes _______________________________________________________________________

(Name of Transporter)

Whose principal place of business is ____________________________ ____________________________ __________ ______________

(Street)

(City)

(State)

(Zip)

And whose field address is _________________________________________________________________________________________

To transport ___________ % of the _________________________________ produced from the well designated above until further notice.

(oil, gas, condensate)

Mode of transportation ________________________________________ Custody transfer point _____________________________________

(pipeline, truck)

(include meter point if applicable)

Other transporters transporting ____________________________________ from the well(s) are:

(oil, gas, condensate)

_______________________________________ _____________ %

______________________________________ ____________ %

(name of transporter)

6. Name of purchaser if different from transporter _______________________________________________________________________

Address _____________________________________ City ___________________________ State ____________ Zip ________________

7. Person to contact

Phone number

regarding this form

Fax number

E-mail address

Remarks:

The undersigned certifies that the above transporting agent is authorized to transport the above specified percentage of the allowable oil, gas, or condensate

produced from the above described well(s) in accordance with the regulations of the State Oil and Gas Board of Alabama Administrative Code and that this

authorization will be valid until further notice or until canceled by the Board, 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 well covered by this report.

__________

________

___________________________________________________

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

________________________________