Form 1022 Covered Offshore Facility Changes

U.S. Department of Interior OMB Control No. 1010-0106

Minerals Management Service OMB Approval Expires: xx/xx/xxxx

COVERED OFFSHORE FACILITY CHANGES

OIL POLLUTION ACT OF 1990 APPLICATION FOR CERTIFICATION OF OIL SPILL FINANCIAL RESPONSIBILITY

(TYPE OR PRINT ALL INFORMATION EXCEPT SIGNATURES)

1. DESIGNATED APPLICANT: ______________________________________________________ ___________________________

COMPANY LEGAL NAME MMS COMPANY NUMBER

2. THE FOLLOWING LIST COMPRISES PART OR ALL OF _____ CHANGES TO LOCATIONS OF COVERED

NUMBER

OFFSHORE FACILITIES OR POTENTIAL WORST CASE OIL-SPILL DISCHARGES LISTED IN THE PREVIOUSLY SUBMITTED APPLICATION FOR CERTIFICATION OF OIL SPILL FINANCIAL RESPONSIBILITY OF _____________.

DATE

____________________________________________ ____________________________________________

NAME OF CORPORATE OFFICER OR DESIGNATED AGENT SIGNATURE OF CORPORATE OFFICER OR DESIGNATED AGENT

_____________________________________________________________________ ____________________

TITLE DATE

3. CHANGES TO LOCATIONS OF COVERED OFFSHORE FACILITIES OR POTENTIAL WORST CASE OIL-SPILL DISCHARGES:

STATE OR OCS REGION	LEASE NUMBER	ALIQUOT PORTION (If Applicable)	AREA NAME	BLOCK NUMBER	PERMIT NUMBER	RIGHT OF USE AND EASEMENT NUMBER	PIPELINE SEGMENT NUMBER	POTENTIAL WORST CASE OIL-SPILL DISCHARGE (In Barrels)	TYPE OF CHANGE * (A/D/N)

*A = ADDITION, D = DELETION, AND N = NEW POTENTIAL WORST CASE OIL SPILL

IF ADDITIONAL SPACE IS REQUIRED, ADDITIONAL COPIES OF THIS PAGE MAY BE ATTACHED AS CONTINUATION PAGES.

MMS FORM MMS-1022 (Mo/Year - Supersedes all previous versions of form MMS-1022 which may not be used). Page 1 of 1