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Home My WebLink AboutTBU Steelhead Platform - Hilcorp Alaska LLCState of Alaska AOGCC Gas Disposition Files Year: 2015 Facility: TBU Steelhead Platform Operator: Hilcorp Alaska LLC STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1330000025 2. Facility Name Trading Bay Unit Steelhead Platform 3. Field Trading Bay Unit McArthur River Field 4. Operator Hilcorn Alaska LLC 5. Month/year of Disposition January -15 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 475,870 Pool Name Pool Code Percent 7. Reinjected Hemlock 520120 3.45% G -Zone 520150 1.847/6 8. Flared or vented 1 hour or less West Foreland 520190 0.00%70 Undefined Zone 520195 0.00% 9. Flared or vented more than 1 hour (see instr.) 0 GGS 520550 9471% 10. Pilot and Purge 6,111 11. Assist Gas 0 12. Fuel gas used in leases operations. 162,188 13. Other (see instructions) Q Official Use Only Authorization >1 hr: Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 644,239 Lease Use MCF 15. NGL Gas Equivalent 0 Conservation MCF 16. Purchased gas 0 Waste: MCF 17. Tmnsferred from: 18. Transferred to: (Express as a negative #) 228,046 Commissioner Date 19. Remarks: Transferred To: TBPF, Dolly, King, TBU A-15 COV's to TBPF 228.046 0 1 hereby car* that the foregoing is true and correct to the best of my knowledge. � Signature ✓126 wsi1I Printed Name Leanne Protz Title Production Analyst Phone 713-757-5211 Date Note: All volumes must be corrected to pressure of 14.65 psis and to a temperature of 60o F. 6/2312015 Form 10422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION VAP, 23 2015 1. Facility Number 1330000025 2. Facility Name Trading Bay Unit Steelhead Platform 3. Field Trading Bay Unit McArthur River Field 4. Operator Hilcorp Alaska LLC 5. Month/Year of Dispose ion February -15 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 457,180 Pool Name Pool Code Percent 7. Reinjected Hemlock 520120 3.25% G -Zone 520150 2.49% 8. Flared or vented 1 hour or less West Foreland 520190 0.00°k80 Undefined Zone 520195 0.00% 9. Flared or vented more than 1 hour (see instr.) GGS 520550 94.26%5 10. Pilot and Purge 5,215 11. Assist Gas 0 12. Fuel gas used in leases operations. 145,757 13. Other (see instructions) U Official Use Only Authorization >1 hr. Safety�� O MCF 14. TOTAL VOLUME (ITEMS 6-13) 608,812 Lease Use MCF 15. NGL Gas Equivalent 0 Conservation MCF 16. Purchased gas 0 Waste: MCF 17. Transferred from: ,///111/� 4 Commissioner Dattel f 18. Transferred to: (Express as a negative #) 164,288 19. Remarks: Transferred To: TBPF, Dolly, King, TBU A-15 COV's to TBPF 164,288 0 1 hereby certify that the foregoing is true and correct to the best of my knowledge. Signature �'( Printed Name Leanne Protz Title Production Analyst Phone 713-757-5211 Date Note: All volumes must be corrected ,Ali of 14.65 psia and to a temperature of 60o F. 3/20/2015 Authority 90 AAr,'25 2,15 VTL- 4116115— Form - 411°1/J Form 10-422 Rev. 512009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate Steelhead Platform February -15 Ht:G.11;IvCL) MAR 2 3 2015 Aor1r.c 500.0 EXCESS FLARING DUE TO EXCESS FLARING NECESSARY 2/1/2015 124250 1330000025 2/5/2015 16:50:00 19:50:00 2/5/2015 U 500 PLATFORM PSD CAUSED BYA GENERATOR GOING UNTIL GENERATOR AND PLATFORM COULD BE BROUGHT DOWN CAUSING A SHUT BACK ONLINE. 500.0 STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1330000025 2. Facility Name Trading Bay Unit Steelhead Platform 3. Field Trading Bay Unit McArthur River Field 4. Operator Hilcor Alaska LLC 5. MonthNear of Disposition March -15 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 447,746 Pool Name Pool Code Percent 7. Reinjected Hemlock 520120 3.25 G -Zone 520150 2.09% 8. Flared or vented 1 hour or less 30 West Foreland 520190 0.00 Undefined Zone 520195 0.00 9. Flared or vented more than 1 hour (see instr.) Q GGS 520550 94.67 10. Pilot and Purge 5,832 11. Assist Gas 0 12. Fuel gas used in leases operations. 162,211 13. Other (see instructions) Q Official Use Only Authorization >t hr. Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 615,819 Lease Use MCF 15. NGL Gas Equivalent 0 Conservation MCF 16. Purchased gas Q Waste: MCF 17. Transferred from: 18. Transferred to: (Express as a negative #) 230,588 Commissioner Date 19. Remarks: Transferred To: TBPF, Dolly, King, TBU A-15 COV's to TBPF 230,588 0 1 hereby certify that the foregoing is true and correct to the best of my knovAedge. Signature i/lYJ7m/. /lfill6 Printed Name Leanne Watkins Title Production Analyst Phone 713-757-5211 Date Note: AN volumes must be corrected to pressure of 14.65 psia and to a temperature of 60o F. 6123/2015 Authority 2n AA CPS 2,11S Form 10422 Rev. 512009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION RECEIVED MAY 2 l 2015 1r" r - 1. Facility Number 1330000025 2. Facility Name Trading Bay Unit Steelhead Platform 3. Field Trading Bay Unit McArthur River Field 4. Operator Hilcor Alaska LLC 5. Month/Year of Disposition Aril -15 Disposition Volume MCF 20. Forproduction from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 419,090 Pool Name Pool Code Percent 7. Reinjected Hemlock 520120 3.51% G -Zone 520150 1.85% 8. Flared or vented 1 hour or less 80 West Foreland 520190 0.00% Undefined Zone 520195 0.00% 9. Flared or vented more than 1 hour (see instr.) 0 GGS 520550 94.64% 10. Pilot and Purge 5,881 11. Assist Gas 0 12. Fuel gas used in leases operations. 157,519 13. Other (see instructions) 0 Official Use Only Authorization >1 hr: Safety MCF 14. TOTAL VOLUME (ITEMS 6.13) 582,570 Lease Use MCF 15. NGL Gas Equivalent 0 Conservation MCF 16. Purchased gas 0 Waste: MCF 17. Transferred from: Commissioner Date 18. Transferred to: (Express as a negative #) 216,071 19. Remarks: Transferred To: TBPF, Dolly, King, TBU A-15 COV's to TBPF 216,071 0 1 hereby certify that the foregoing is true and correct to the best of my knowledge. Signature Printed Name Leanne Watkins Title Production Analyst Phone 713-757-5211 Date Note: volumes must be corrected to All pressure of 14.65 psia and to a temperature of 60o F. 5115/20151 Authnritil 5>0 AAr2,15 X3.5 Form 10-422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1330000025 2. Facility Name Trading Bay Unit Steelhead Platform 3. Field Trading Bay Unit McArthur River Field 4. Operator Hilcory Alaska LLC 5. MonthNear of Disposition May -15 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 399,896 Pool Name Pool Code Percent 7. Reinjected Hemlock 520120 3.73% G -Zone 520150 2.06% 8. Flared or vented 1 hour or less 0 West Foreland 520190 0.00% Undefined Zone 520195 0.00°/. 9. Flared or vented more than 1 hour (see instr.) 0 GGS 520550 94.21% 10. Pilot and Purge 6,019 11. Assist Gas 0 12. Fuel gas used in leases operations. 164,347 13. Other (see instructions) Q Official Use Only Authorization>1 hr: Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 570,262 Lease Use MCF 15. NGL Gas Equivalent 0 Conservation MCF 16. Purchased gas Q Waste: MCF 17. Transferred from: Commissioner Date 18. Transferred to: (Express as a negative #) 228,932 19. Remarks: Transferred To: TBPF, Dolly, King, TBU A-15 COV's to TBPF 228,932 0 1 hereby certify that the foregoing is true and correct to the best of my knowledge. Signature Printed Name Leanne Watkins Title Production Analyst Phone 713-757-5211 Date Note: All volumes must be corrected to pressure of 14.65 psia and to a temperature of 60o F. 6/15/2015 Authnnity 20 AAC�5 2.q.5 Form 10-422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 7330000025 2. Facility Name Trading Bay Unit Steelhead Platform 3. Trading Bay Unit McArthur River Field 4. Operator5. Hilcor Alaska LLC Month/Year of Disposition June -15 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 386,613 Pool Name Pool Code Percent 7. Reinjected Hemlock 520120 3.37% G -Zone 520150 1.92% 8. Flared or vented 1 hour or less 1,220 West Foreland 520190 0.00% Undefined Zone 520195 0.007% 9. Flared or vented more than 1 hour (see instr.) 0 GGS 520550 94.71% 10. Pilot and Purge 5,696 11. Assist Gas 0 12. Fuel gas used in leases operations. 151,000 13. Other (see instructions) 0 Official Use Only Authorization >1 hr: Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 544,529 Lease Use MCF 15. NGL Gas Equivalent 0 Conservation MCF 16. Purchased gas 2,0 1Waste: I IMCF 17. Transferred from: Commissioner Date 18. Transferred to: (Express as a negative #) 210.508 19. Remarks: Purchased from CIGGS 2,062 Transferred To: TBPF, Dolly, King, TBU A-15 210,508 COV's to TBPF 0 1 hereby certify that the foregoing is true and correct to the best of my knowledge. Note: All volumes must be Signature �T6 Title Production Analyst corrected to pressure of 14.65 psia Printed and to a temperature of 60o F. Name Leanne Watkins Phone 713-757-5211 Date 7/17/2015 Aiithnrity 2n AAr25 2.15 Form 101122 Rev. 512009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1330000025 2. Facility Name Trading Bay Unit Steelhead Platform 3, Trading Bay Unit McArthur River Field 4. Operator5. Hilcor Alaska LLC Month/Year of Disposition July -15 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 375,068 Pool Name Pool Code Percent 7. Reinjected Hemlock 520120 3.43% G -Zone 520150 1.81% 8. Flared or vented 1 hour or less 600 West Foreland 520190 0.00% Undefined Zone 520195 0.00% 9. Flared or vented more than 1 hour (see instr.) 0 GGS 520550 94.76% 10. Pilot and Purge 6,137 11. Assist Gas 0 12. Fuel gas used in leases operations. 160,510 13. Other (See instructions) 0 Official Use Only Authorization >1 hr: Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 542,315 Lease Use MCF 15. NGL Gas Equivalent 0 Conservation MCF 16. Purchased gas 753 Waste: JMCF 17. Transferred from: 18. Transferred to: (Express as a negative #) 220,460 Commissioner Date 19. Remarks: Purchased from CIGGS 753 Transferred To: TBPF, Dolly, King, TBU A-15 220,460 COV's to TBPF 0 1 hereby certify that the foregoing is true and correct to the best of my knowledge. Note: All volumes must be Tommi Signature Title Production Analyst corrected to pressure of 14.65 psis Printed and to a temperature of 60o F. Name Leanne Watkins Phone 713-757-5211 Date 8/17/20151 Aiithnritv 2QAAr9J5 2.1.5 Form 10-422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1330000025 2. Facility Name Trading Bay Unit Steelhead Platform 3. Trading Bay Unit McArthur River Field 4. Operator Hilcor Alaska LLC 5. Month/Year of Disposition August -16 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 348,950 Pool Name Pool Code Percent 7. Reinjected Hemlock 520120 2.02% G -Zone 520150 1.65% 8. Flared or vented 1 hour or less 80 West Foreland 520190 0.00% Undefined Zone 520195 0.00% 9. Flared or vented more than 1 hour (see instr.) 0 GGS 520550 96.33% 10. Pilot and Purge 6,655 11. Assist Gas 0 12. Fuel gas used in leases operations. 158,175 13. Other (see instructions) Q Official Use Only Authorization>t hr: Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 513,860 Lease Use MCF 15. NGL Gas Equivalent 0 Conservation MCF 16. Purchased gas 0 Waste: MCF 17. Transferred from: Commissioner Date 18. Transferred to: (Express as a negative #) 226,458 19. Remarks: Purchased from CIGGS 0 Transferred To: TBPF, Dolly, King, TBU A-15 226,458 COV's to TBPF 0 1 hereby certify that the foregoing is true and correct to the best of my knowledge. Signature ZGi4i Title Production Analyst Note: All volumes must be corrected to pressure of 14.65 psia and to a temperature of 60o F. Ainthnritv 20 AA(79.5 2.15 Printed Name Leanne Watkins Phone 713-757-5211 Date 9/18/2015 Form 10-422 Rev. 512009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1330000025 2. Facility Name Trading Bay Unit Steelhead Platform 3. Trading Bay Unit McArthur River Field 4. Operator Hilcor Alaska LLC 5. MonthNear of Disposition Se tember-15 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 291,350 Pool Name Pool Code Percent 7. Reinjected Hemlock 520120 3.60% G -Zone 520150 2.47°/, 8. Flared or vented 1 hour or less 1 West Foreland 520190 0.00% Undefined Zone 520195 0.00% 9. Flared or vented more than 1 hour (see instr.) 930 GGS 520550 93.93% ' 10. Pilot and Purge 6,267 11. Assist Gas 0 12. Fuel gas used in leases operations. 146,425 13. Other (see instructions) 0 Official Use Only � 0 Authorization >1 hr: Safety MCF 14. TOTAL VOLUME (ITEMS 6.13) 444,91. Lease Use MCF 15. NGL Gas Equivalent 0 Conservation MCF 16. Purchased gas p Waste: MCF 17. Transferred from: ® L —4:5- 18. Transferred to: (Express as a negative #) 218,939 Commissioner Date ' 19. Remarks: Purchased from CIGGS 0 Transferred To: TBPF, Dolly, King, TBU A-15 218,939 COV's to TBPF 0 1 hereby certify that the foregoing is true and correct to the best of my knowledge. Note: All volumes must be Signature ioinmi�.ni1 Title Production Analyst corrected to pressure of 14.65 psia Printed and to a temperature of 60o F. Name Leanne Watkins Phone 713-757-5211 Date 10/19/20151 Authority 20 AAC25 2.1.5 Form 10422 Rev. 512009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate Steelhead Platform September -15 930.0 EXCESS FLARING DUE TO SKID EXCESS FLARING NECESSARY UNTIL BLOW DOWNS DURING C12 AND LIQUIDS UNLOADING COULD BE 9/1/2015 124250 1330000025 9/11/2015 0:00:00 11:00:00 9/11/2015 U 240 C13 SWAPS AND STARTUP COMPLETE AND COMPRESSORS ATTEMPTS. BROUGHT BACK ONLINE. EXCESS FLARING DUE TO LIQUIDS EXCESS FLARING NECESSARY UNTIL 9/1/2015 124250 1330000025 9/13/2015 15:00:00 0:59:00 9/14/2015 P 290 UNLOADING OF WELL M-3. LIQUIDS UNLOADING COULD BE COMPLETE AND WELL BROUGHT BACK ONLINE. EXCESS FLARING DUE TO LIQUIDS EXCESS FLARING NECESSARY UNTIL 9/1/2015 124250 1330000025 9/15/2015 11:00:00 16:00:00 9/15/2015 P 400 UNLOADING OF WELL M-3. LIQUIDS UNLOADING COULD BE COMPLETE AND WELL BROUGHT BACK ONLINE. 930.0 STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1330000025 2. Facility Name Trading Bay Unit Steelhead Platform 3. Trading Bay Unit McArthur River Field 4. Operator Hilcorp AlaskaLLC 5. MonthNear of Disposition October -15 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 255,538 Pool Name Pool Code Percent 7. Reinjected Hemlock 520120 3.89% G -Zone 520150 2.99% 8. Flared or vented 1 hour or less 910 West Foreland 520190 0.00% Undefined Zone 520195 0.00% 9. Flared or vented more than 1 hour (see instr.) 0 GGS 520550 93.11% 10. Pilot and Purge 6,901 11. Assist Gas 0 ' 12. Fuel gas used in leases operations. 147,014 ' 13. Other (see instructions) Q Official Use Only Authorization >1 hr: Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 410,363 Lease Use MCF 15. NGL Gas Equivalent 0 Conservation MCF 16. Purchased gas Q Waste: MCF 17. Transferred from: 18. Transferred to: (Express as a negative #) 221,914 Commissioner Date ' 19. Remarks: Purchased from CIGGS 0 Transferred To: TBPF, Dolly, King, TBU A-15 221,914 COV's to TBPF 0 1 hereby certify that the foregoing is true and correct to the best of my knowledge. o - Note: All volumes must. be Signature 9i19G X Title Production Analyst corrected to pressure of 14.65 psia Printed and to a temperature of 60o F. Name Leanne Watkins Phone 713-757-5211 Date 11/18/2015 Form 10-422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1330000025 2. Facility Name Trading Bay Unit Steelhead Platform 3. Trading Bay Unit McArthur River Field 4. Operator Hilcor Alaska LLC 5. /Year of Disposition November -15 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 245,742 Pool Name Pool Code Percent 7. Reinjected Hemlock 520120 3.87% G -Zone 520150 1.95% 8. Flared or vented 1 hour or less 813 West Foreland 520190 0.00% Undefined Zone 520195 0.007/0 9. Flared or vented more than 1 hour (see instr.) 63 GGS 520550 94.18% 10. Pilot and Purge 7,123 11. Assist Gas 0 12. Fuel gas used in leases operations. 144,746 13. Other (see instructions) Q Official Use Only Authorization >1 hr: Safety 63 MCF 14. TOTAL VOLUME (ITEMS 6-13) 398,489 Lease Use MCF 15. NGL Gas Equivalent Q Conservation MCF 16. Purchased gas Q Waste: JMCF 17. Transferred from: Commissioner Date 18. Transferred to: (Express as a negative #) 212,859 19. Remarks: Purchased from CIGGS 0 Transferred To: TBPF, Dolly, King, TBU A-15 212,859 COV's to TBPF 0 1 hereby certify that the foregoing is true and correct to the best of my knowledge. Note: All volumes must be Signature Title Production Analyst corrected to pressure of 14.65 psia Printed and to a temperature of 60o F. Name Leanne Watkins Phone 713-757-5211 Date 12/17/2015 Aiithnrity 91) AAr2.5 235 Form 10-422 Rev. 512009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate l,'rL 115 -111 - Steelhead Platform November -15 63.0 63.0 EXCESS FLARING DUE TO COMPRESSOR 22 DOWN FOR TIE- IN EXCESS FLARING NECESSARY UNTIL THE TIE-IN COMPLETE AND COMPRESSOR BROUGHT BACK ONLINE. 11/1/2015 124250 1330000025 11/5/2015 0:00:00 3:00:00 11/5/2015 P 63.0 STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1330000025 2. Facility Name Trading Bay Unit Steelhead Platform 3, Trading Bay Unit McArthur River Field 4. Operator Hilcorp Alaska LLC 5. MonthlYear of Disposition December -15 Disposition Volume MCF 20. Forproduction from multiple pools, list contribution of each pool as a pement of Total Volume. 6. Sold 267,951 Pool Name Pool Code Percent 7. Reinjected Hemlock 520120 3.49% G -Zone 520150 2.35% 8. Flared or vented 1 hour or less 580 West Foreland 520190 0.00% Undefined Zone 520195 0.00° 9. Flared or vented more than 1 hour (see insh.) 0 GGS 520550 94.16% 10. Pilot and Purge 7,5 11. Assist Gas 0 12. Fuel gas used in leases operations. 146,282 13. Other (see instructions) Q Official Use Only Authorization >1 hr: Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 422,396 Lease Use MCF 15. NGL Gas Equivalent 0 Conservation MCF 16. Purchased gas 0 Waste: I MCF 17. Transferred from: Commissioner Date 18. Transferred to: (Express as a negative #) 231,5$1 19. Remarks: Purchased from CIGGS 0 Transferred To: TBPF, Dolly, King, TBU A-15 231,581 COV's to TBPF 0 1 hereby certify that the foregoing is true and correct to the best of my knoviledge. Note: All volumes must be Signature ./17.6 � Title Production Analystcorrected to pressure of 14.65 psra Printed and to a temperature of 60o F. Name Leanne Watkins Phone 713-757-5211 Date 1/20/2016AAC25 235, Form 10422 Rev. 512009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate