OKLAHOMA CORPORATION COMMISSION

Oil and Gas Conservation Division
P.O. Box 52000
Oklahoma City, OK 73152-2000

Spill Discharge Report Form

Type of Party Reporting:

Name of Party Reporting (Optional):

Address:

City: State: 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:  On-going:

Approximately how many barrels of substance was recovered:  Barrels