Date: E-Mail: Title: Reported by: __________________________________________________________________________________ Method of Cleanup/Action Taken/Time Required for Cleanup: Other Detail:    Bbls   Disposal Facility Name      Other Lands Affected: Other Agencies Contacted: Contained on Lease: Produced Water How Incident Occurred:      Bbls   Bbls __________________________________________________________________________________ Produced Water: Bbls Oil:   Bbls    Gas: Mcf      Bbls   Time to Control Incident: Volumes Recovered / Placed back into Production:   Produced Water:   Oil: Volumes Spilled/Released: Other: 7. DESCRIPTION OF INCIDENT 6. TYPE OF INCIDENT Other Facility Tank 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 Button Usage:

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        Volume Recovered / Hauled to Disposal Facility:   Oil