Refiner's Monthly Report - Form 13

Refiner's Monthly Report - Form 13 Department of Mineral Resources Oil and Gas Division 600 East Boulevard Dept 474 Bismark, N.D 58505 to 0614 S.F.N 18672 (04 to 2000)

Checkbox option: Amended

Please Read Instructions Before Filling Out Form.

Please Submit the Original.

Field: For Month/Year

Field: Name of Refinery

Field: Telephone Number

Field: Main Office Address

Field: City

Field: State

Field: Zip Code

Field: Refinery Address

Field: City

Field: State

Field: Zip Code

Type Stock on Hand Beginning of Month (Bbls) Receipts (Bbls) Runs to Still, Re-runs, and/or Blended (Bbls) Production (Bbls) Plant Use and Losses (Bbls) Stock on Hand End of Month (Bbls)

Field: Crude Oil

Field: Propane

Field: Butane

Field: Casinghead Gasoline

Field: Gasolines (total all grades)

Field: Fuel Oils (total all grades)

Field: Diesel Fuel

Field: Distillate Fuel

Field: Cracking Stock

Field: Jet Fuel

Field: Residuals

Field: Other

Field: Comments

I hereby swear or affirm that the information provided is true, complete and correct as determined from all available records.

Field: Date

Field: Signature

Field: Printed Name

Field: Title

Above Signature Witnessed By

Field: Witness Signature

Field: Witness Printed Name

Field: Witness Title

Refiner's Monthly Report - Form 13 S.F.N 18672

1. This report is required as a regular monthly report, regardless of the status of operations.

2. Please refer to Section 43-02-03-82 of the North Dakota Administrative Code regarding reporting requirements for oil refiners.

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

4. If this is an amended report, the amended volumes shall be clearly indicated.

5. The original 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, by the fifteenth day of the second succeeding month.