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Clearwater Oil Company, Ltd.

Big Bear Lease No. 2 Production Facility

SAMPLE Spill Prevention, Control, and

Countermeasure (SPCC) Plan

Discharge Notification Form

*** Notification must not be delayed if information or individuals are not available.

Facility: Clearwater Oil Company Big Bear Lease No. 2 Production Facility

5800 Route 417, Madison, Louisiana 73506

Description of Discharge

Date/time

Release date:

Release time:

Duration:

Discovery date:

Discovery time:

Reporting Individual

Name:

Tel. #:

Location of discharge

Latitude:

Longitude:

Description:

Equipment source

G piping

G flowline

G well

G unknown

G stock, flare

Description:

Equipment ID:

Product

G crude oil

G saltwater

G other*

* Describe other:

Appearance and description

Environmental conditions

Wind direction:

Wind speed:

Rainfall:

Current:

Impacts

Quantity

Released:

Recovered:

Receiving medium

G water**

G land

G other (describe):

G Release confined to company property.

G Release outside company property.

** If water, indicate extent and body of water:

Describe circumstances of the release

Assessment of impacts and remedial actions

Disposal method for recovered material

Action taken to prevent incident from reoccurring

-X-

Version 1.0, 11/28/2005

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