Form MMS-1021 Covered Offshore Facilities

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

Bureau of Ocean Energy Management, OMB Approval Expires: xx/xx/xxxx

Regulation and Enforcement

COVERED OFFSHORE FACILITIES

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 BOEMRE COMPANY NUMBER

2. THE FOLLOWING LIST COMPRISES PART OR ALL OF _____ LOCATIONS OF COVERED OFFSHORE FACILITIES

NUMBER

TO BE COVERED BY MY APPLICATION FOR CERTIFICATION OF OIL SPILL FINANCIAL RESPONSIBILITY.

____________________________________________ ____________________________________________

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

_____________________________________________________________________ ____________________

TITLE DATE

3. LOCATIONS OF COVERED OFFSHORE FACILITIES:

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)

BOEMRE FORM MMS-1021 (Mo/Year – Supersedes all previous versions of form MMS-1021 which may not be used). Page 1 of 2

3. LOCATIONS OF COVERED OFFSHORE FACILITIES (continued):

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)

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

BOEMRE FORM MMS-1021 (Mo/Year – Supersedes all previous versions of form MMS-1021 which may not be used). Page 2 of 2