Type of Party Reporting: Please choose a Type Citizen Company Anonymous

Name of Party Reporting (Optional):

Address:

City: State: Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip Code:

Phone: Cell Phone:

Location of Spill:

Name of Lease/Facility/Pipeline:

Contact Person: Phone No:

Section: Township: Range: Qtr: Qtr: Qtr:

Latitude/Longitude:

Description of circumstances surrounding the discharge:

Was discharge primarily over (please check one): Land Water

Date of Discharge (MM/DD/YYYY):

Estimate Volume (in barrels) of Discharge:  Barrels

Type of Material Discharged: Oil  Salt Water: Other:(Please describe):

Method of Clean-up:

Is clean-up completed:  Select One Yes No On-going: Select One Yes No

Approximately how many barrels of substance was recovered:  Barrels