Date: E-Mail: Title: Reported by: __________________________________________________________________________________ Method of Cleanup/Action Taken/Time Requried for Cleanup: Other Detail:      Other Lands Affected? Other Agencies Contacted? Contained on Lease? How Incident Occurred: Mcf Gas: Bbls __________________________________________________________________________________ Produced Water: Bbls Oil:   Bbls    Gas: Mcf      Bbls   Time to Control Incident: Volumes Recovered:   Produced Water:   Oil: Volumes Spilled/Released: Other: 7. DESCRIPTION OF INCIDENT 6. TYPE OF INCIDENT Other Facility Battery Name 3. API Number Well Name __________________________________________________________________________________      5. Surface Lease Type: North UTM Coordinates: East       County Range Township Section 4. Location: Qtr/Qtr Time of Incident: 2. Date of Incident: Phone: 1. Operator __________________________________________________________________________________                         - -      - : -     UTAH DIVISION OF OIL, GAS AND MINING INCIDENT REPORT Please use your web browser printing functions to print a copy of this report for your records prior to submitting it.