Fillable Form 12 - Gas Facility Registration/change Of Operator printable pdf download

Form 12 - Gas Facility Registration/change Of Operator

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FORM

State of Colorado

FOR OGCC USE ONLY

Rev 6/99

Oil and Gas Conservation Commission

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

GAS FACILITY REGISTRATION/CHANGE OF OPERATOR

Use one copy of Form 12 for each facility being registered/change of operator. Per Rule 711, an operator is to

provide financial assurance to ensure compliance with the 900 Series rules in the amount of $50,000 or in an

amount voluntarily agreed to with the Director, or in an amount to be determined by order of the Commission.

Operators of small systems gathering or processing less than five MMSCFD may provide individual financial

Complete the

assurance in the amount of $5,000. A facility map must accompany each new registration.*

Attachment Checklist

OGCC Operator Number:____________________________

Contact Name and Telephone:

Oper

OGCC

________________________________________

Facility Map

Name of Operator:___________________________________________

No:______________________________

Address:___________________________________________________

Fax:_____________________________

City:__________________________ State:_____ Zip:______________

Operator’s Facility Name and Number:________________________________________________________________

Location (QtrQtr, Sec, Twp, Rng, Meridian): ___________________________________________________________

Address: _______________________________________________________________________________________

City: _________________________________ State: ____ Zip: _______________ County: ______________________

REGISTRATION

TYPE OF OPERATION

GAS-PROCESSING PLANT

GATHERING SYSTEM

STORAGE FACILITY

*A facility map must accompany each new registration and be resubmitted when significant changes have been made to the facility.

All gathering and distribution maps are to be submitted at a scale no smaller than 1:24,000; all processing facilities at a scale no smaller than 1:100.

All maps may be submitted digitally using DWG or DXF formats.

Estimated Daily Processing Total: ___________________________ MMSCFD

Is the facility within a sensitive area according to Rule 901.e?

Yes

CHANGE OF OPERATOR

Seller’s Signature

Name of Operator

Operator Number

Title

Date

Buyer or Current Operator

I hereby certify that the statements made in this form are, to the best of my knowledge, true, correct, and complete.