Fillable DIVISION OF NATURAL RESOURCES AND SAFETY (Pawnee Nation)

Fill Online, Printable, Fillable, Blank DIVISION OF NATURAL RESOURCES AND SAFETY (Pawnee Nation) Form

Use Fill to complete blank online PAWNEE NATION pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

DIVISION OF NATURAL RESOURCES AND SAFETY (Pawnee Nation)

On average this form takes 78 minutes to complete

The DIVISION OF NATURAL RESOURCES AND SAFETY (Pawnee Nation) form is 8 pages long and contains:

  • 8 signatures
  • 28 check-boxes
  • 265 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Pawnee Nation forms online.

BROWSE PAWNEE NATION FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Spill #:
Spill Name:
*FOR AGENCY USE*
DIVISION OF NATURAL RESOURCES AND
SAFETY
301 Agency Road, Pawnee, OK 74058 | Phone: 918.762.3655 | Fax: 918.762.6461
This form shall be completed and submitted to the Pawnee Nation Division of Natural Resources and Safety by the operator responsible for the
spill or release within 24 hours of spill discovery. Any release which threatens or reaches waters of the U.S. must be reported as soon
as practicable. This form can be submitted by emailing the completed form DNRS@pawneenation.org.This form must be accompanied by a
topographic or aerial map showing the release location and extent.
OPERATOR INFORMATION
INITIAL SPILL/RELEASE REPORT
Initial Report Date: Date of Discovery: Spill Type:
Spill/Release Point Location:
Legal Description of Release Location: QTRQTR SECTION TWP
Latitude: RANGE MERIDIAN
Longitude: Allotment Name: Allotment Number:
(decimal degrees)
***A location map MUST be provided with this spill report***
Reference Location: (Well, ROW, CDP, Disposal Well, etc.)
Facility Type: Facility Name:
Spill/Release Details:
Was one (1) barrel or more spilled outside of berms or secondary containment?
Were five (5) barrels or more spilled?
**Secondary containment must be sufficiently impervious to contain any discharge from primary containment until cleanup occurs**
Estimated Total Spill Volumes
Estimated Oil Spill Volume (bbl): Estimated Condensate Spill Volume (bbl):
Estimated Flowback Fluid Spill Volume (bbl): Estimated Produced Water Spill Volume (bbl):
Estimated Other E&P Spill Volume (bbl): Estimated Drilling Fluid Spill Volume (bbl):
Amount Recovered (bbl):
Description of event including what happened and how the release was responded to:
Land Use:
Current Land Use: Other (Specify):
Weather Conditions:
Surface Owner: Other (Specify):
Check if impacted or threatened by spill/release (Check all that apply):
Waters of the U.S. Residence/Occupied Structure Livestock Public Byway Surface Water Supply Area
Ground Water Supply
Ag Resources Wildlife/Habitat Other:
Name of Operator: Operator No.:
Address: Phone:
City:
State:
Zi
p:
M
obile
:
Contact Person: Email:
NOTIFICATIONS
Signed: Print Name:
Document Name Description
Date Agency
Phone
Contact Person Response
OPERATOR CERTIFICATION STATEMENT
ATTACHMENTS
I hereby certify that all statements made in this form are to the best of my knowledge true, correct, and complete.
Title: Date: Email:
Additional Comments/Information
FINAL CLOSURE CERTIFICATION
Instructions: Operator must resubmit this form along with documentation of closure activities within 30 days of completion of
closure
activities. Do not complete this portion until closure activities are complete.
Federal Concurrences Attached Date:
Comments:
I hereby certify that the spill detailed above has been remediated in accordance with regulatory requirements and tribal
requests, and all information submitted in connection with this spill and closure activities is true, accurate, and complete to
the best of my knowledge.
Signature: Title:
Name: Date:
Email:
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

DIVISION OF NATURAL RESOURCES AND SAFETY (Pawnee Nation)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 31 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document