Oil Transporters And Storers Monthly Report - Form 10b

Department of Mineral Resources Oil and Gas Division 600 East Boulevard Dept 474 Bismark, N.D: 58505 to 0614 S.F.N 5523 (09 to 2009)

Field: Page

Field: of

Checkbox option: Amended

Please Read Instructions Before Filling Out Form.

Please Submit the Original.

Field: For Month/Year

Field: Transporter

Field: Telephone Number

Field: Address

Field: City

Field: State

Field: Zip Code

Deliveries

Field: Point Received

Field: Purchaser

Field: Destination

Field: Quantity (Bbls)

Field: Monthly Total

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

Oil Transporters and Storers Monthly Report - Form 10B S.F.N 5523

1. This report shall be submitted by the transporter, handler, or storer of crude oil.

2. All volumes of crude oil or other liquid hydrocarbons transported from each station or point received shall be reported.

3. All volumes shall be shown as barrels (42 gallons), corrected to 14.7 psia and 60 degrees F. All volumes shall be shown to the nearest full barrel.

4. Under the column headed "Point Received" the field, station, or other transport point shall be listed.

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

6. 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 first day of the second succeeding month.