Form 19 - Oil And Gas Conservation Commission/spill/release Report

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FORM

FOR OGCC USE ONLY

State of Colorado

Rev 6/99

Oil and Gas Conservation Commission

1120 Lincoln Street, Suite 801, Denver, Colorado 80203 (303)894-2100 Fax:(303)894-2109

SPILL/RELEASE REPORT

Spill report taken by:

This form is to be submitted by the party responsible for the oil and gas spill or release. Any spill or

release which may impact waters of the State must be reported as soon as practicable; any spill over 20

bbls must be reported within 24 hours and all spills over five bbls must be reported within ten days.

FACILITY ID:

Submit a Site Investigation and Remediation Workplan (Form 27) when requested by the Director.

OPERATOR INFORMATION

Name of Operator: ______________________________ OGCC Operator No: ___________________

Phone Numbers

Address: __________________________________________________________________________

No: ___ _____________________________

City: ____________________________________________ State: _____ Zip: ___________________

Fax: ________________________________

Contact Person: ____________________________________________________________________

E-Mail:_______________________________

DESCRIPTION OF SPILL OR RELEASE

County: ______________________________

Date of Incident : _____________ Facility Name & No.: _____________________________________

QtrQtr: _____________ Section: ___________

Type of Facility (well, tank battery, flow line, pit): ___________________________________________

Township: ____________ Range: __________

Well Name and Number: _____________________________________________________________

Meridian: _____________

API Number: ______________________________________________________________________

Specify volume spilled and recovered (in bbls) for t h e following materials:

Oil spilled: _________ Oil recov’d: _________ Water spilled: _________ Water recov’d: _________ Other spilled: _________ Other recov’d:__________

Ground Water impacted?

Yes

Surface Water impacted?

Yes

Contained within berm?

Yes

Area and vertical extent of spill: ________________x________________________

Current land use: _____________________________________________ Weather conditions: _____________________________________________

Soil/geology description: _____________________________________________________________________________________________________

IF LESS THAN A MILE, report distance IN FEET to nearest…. Surface water: __________ wetlands: __________ buildings: __________

Livestock: ___________ water wells: __________ Depth to shallowest ground water: __________

Cause of spill (e.g., equipment failure, human error, etc.): _____________________________________ Detailed description of the spill/release incident:

CORRECTIVE ACTION

Describe immediate response (how stopped, contained and recovered):

Describe any emergency pits constructed:

How was the extent of contamination determined:

Further remediation activities proposed (attach separate sheet if needed):

Describe measures taken to prevent problem from reoccurring:

OTHER NOTIFICATIONS

List the parties and agencies notified (County, BLM, EPA, DOT, Local Emergency Planning Coordinator or other).

Date

Agency

Contact

Phone