Tank Bottom Cleaning Report - Form 23

Tank Bottom Cleaning Report - Form 23 Department of Mineral Resources Oil and Gas Division 600 East Boulevard Dept 474 Bismark, N.D 58505 to 0614 S.F.N 16606 (03.2004)

Field: Well File No.

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Please Read Instructions Before Filling Out Form.

Field: Date Tank Cleaning Completed

Please Submit the Original and One Copy.

Well Name and Number Field

Field: Location of Well or Facility

Field: Qtr-Qtr

Field: Section

Field: Township

Field: Range

Field: County

Field: N

Field: W

If Tank(s) is/are Located at a Centralized Facility, Attach a Supplemental List of all Well Names, Well File Nos. and Legal Description of Wells.

Field: Location of Tank (if not on lease)

Field: Operator

Field: Telephone Number

Field: Address

Field: City

Field: State

Field: Zip Code

Field: Capacity of Tank(s) Bbls

Field: Commission Representative Verbally Authorizing Work

Field: Date Work Authorized

Tank Bottoms = Salable Oil Recovered After Treatment + Waste Oil Remaining + B.S&W Remaining

Field: Tank Bottoms (Bbls)

Field: Salable Oil Recovered After Treatment (Bbls)

Field: Waste Oil Remaining (Bbls)

Field: B.S&W Remaining (Bbls)

Field: Transporter of Salable Oil After Treatment

Field: Purchaser of Salable Oil

Field: Transporter of Waste Oil

Field: Purchaser of Waste Oil

Field: Transporter of B.S&W

Field: Destination of B.S&W

Well Name(s) to be Credited with Salable Oil and/OR Waste Oil Sold (Attach List if Additional Room is Needed)

Field: Well Name and Number

Field: Well File Number

Field: Salable Oil Credited (Bbls)

Field: Salable Waste Oil Credited (Bbls)

Field: Comments

Field: Operator

Field: Telephone Number

for State Use Only

Checkbox option: Received

Checkbox option: Approved

Field: Address

Field: City

Field: State

Field: Zip Code

Field: Date

Field: Signature

Field: Printed Name

Field: By

Field: Title

Field: Date

Field: Title

Tank Bottom Cleaning Report - Form 23 S.F.N 16606

1. This report shall be filed by the operator with the Commission within thirty (30) days after completing a tank cleaning.

2. Please refer to Section 43-02-03-50 NDAC regarding tank cleaning.

3. No tank bottom shall be removed from any tank used for the storage of crude oil or a tank in which crude oil might accumulate without prior approval.

4. Verbal approval may be given by a Commission representative authorizing the tank cleaning.

5. The name of the Commission representative verbally authorizing the work and the date the work was authorized shall be included on the report.

6. The well file number, well name and number, field, well or facility location, and operator of the well or facility shall coincide with the official records on file with the Commission. The wells to be credited with oil sold shall be clearly identified by well name and number and well file number. The well names and numbers and file numbers shall coincide with the official records on file with the Commission.

7. The amount of merchantable oil shall be determined from a representative sample of the tank bottoms by a standard centrifugal test as prescribed by A.P.I standards.

8. All salable oil volumes shall be reported as barrels (42 gallons) corrected to 60 degrees F. and 14.73 psia. All other volumes shall be reported as barrels (42 gallons). All volumes shall be rounded to the nearest full barrel.

9. All tank bottom waste shall be disposed of in accordance with all applicable local, state, and federal laws and regulations.

10. The original and one copy of this report shall be filed with the Department of Mineral Resources, Oil and Gas Division, 600 East Boulevard, Dept. 474, Bismarck, N.D 58505 to 0614.