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Home My WebLink AboutColville River Unit - ConocoPhillips Alaska Inc.State of Alaska AOGCC Gas Disposition Files Year: 2016 Facility: Colville River Unit Processing Operator: ConocoPhillips Alaska, Inc. STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1030000017 2. Faality Name Colville River Unit Processing Facility 3. Feld Colville River UnR 4. Operator CONOCOPHILLIPS ALASKA, INC. 5. MonlKlYear of Dispositlon January -16 Disposition Volume MCF 20. Forproduction from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 44,169 Pool Name Pool Code Percent 7. Reinjected 1,546,937 ALPINE 120100 -644% FIORD 120120 -e9:w 8. Flared or vented 1 hour or less 1.310 NANUQ 120175 427 NANUQ-KUPARUK 9. Flared or vented more than 1 hour (see Instr.) 3,825 QANNIK 120180 1.4% OTHER 10. Pilot and Purge 14,561 11. Assist Gas 100.0% — 12. Fuel gas used in lease operations. 465,249 13. Other (see instructions) Authoroation>1 hr. Safety 3 O Z MCF 14. TOTAL VOLUME (ITEMS 6-13) 2,096,051 Lease Use MCF 15, NGL Gas Equivalent Conservation MCF 16. Purchased gas Waste: MCF 17. Transferred from:[JA7 / '/ 3 _ _/ el Commissioner "' Date 18. Transferred to: (Express as a negative 0) 19. Remarks: Gas sold to Alpine Transportation Company= 29,057 Gas gifted to Village of Nuiqsut = 15,112 I hereby certify that the foregoinA Is true a Signature: d correct to the best of my.knoMedge. Title: Revenue 8 Regulatory Analyst Note: All volumes must be corrected to pressure of 14.65 psla and to a temperatureof604F. Authorify20 AAC25.235. Printed Name: Lisa Dwineller Phone: (918) 681-5616 Date: February 19, 2016 Form Form 10-422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate shtill�e W bN.S 29•`L� CONOCOPHILLIPS ALASKA, INC CONSERVATION ORDER NO. 443 ALPINE ALPINE PROCESSING FACILITY GAS FLARING INCIDENTS Total Flare > 1 Hour 3,825 Total Flare c 1 Hour 1,310 Pilot and Purge 14,561 Total Flare 19,696 Jan -16 START END PLANNED VOLUME DATE TIME DATE TIME UNPLANNED (MSCF) DESCRIPTION OF FLARING EVENT ACTION TAKEN TO MINIMIZE VOLUME 1/6/2016 12:37 1/6/2016 14:43 UNPLANNED Flared on meter 35011 - Loss of Generator G- Restart Turbine G -70001/C-33012 70001 - Full Facility Shutdown. 66 1/62015 15:10 116/2016 19:54 UNPLANNED Flared on meter 35011 - Loss of Generator G- Restart Turbine G -70001/C-33012 70001 - Full Facility Shutdown. 3262 Flared on meter 35012 - Loss of Generator G Restart Turbine G -70001/C-33012 1/62016 15:27 1162016 17:31 UNPLANNED 497 70001- Full Facility Shutdown. Total Flare > 1 Hour 3,825 Total Flare c 1 Hour 1,310 Pilot and Purge 14,561 Total Flare 19,696 GAS FLARING or VENTING REPORT - CONOCOPHILLIPS ALASKA, INC. FACILITY: Alpine AIR PERMIT NUMBER: AQ0469TVPOI GAS DISPOSITION - Date of Odcunencot 1/6/2016 ❑+ (fare ❑Yuri Tlma of Occurrence: (mmlddiyy) (Check Selection) 49:42 am Mkod From: 15:27 To: 17_31 0204 Total Volume Flared or Vented: 497 MSCF BBLS From: To: _ _ Planned ❑ Unplanned 17 From: To: _ From: To: Meter No: MTRJ5012 (By Facility) Total Mlmaec Hare. erVemed M04 (Indude. vcums flared which peneremd blarw.moke, g applicable) A. Description of Incident and Cause:Chaskasmany as needed to fdlyisecid SID Yfor % lemonss feat in Leas of GenandorG.70001 TIC SD due In Ingh.s Beet tempareurt, aeGbn olfaclllly EMERGENCY SHMOMM Fetlng for ddllsha shutdown 1 sedan X Electrical I Instrumentation melfuncush Flare syabm lesgng EseessiveMsulReient Intel gas mt.. into facility Faulty shuirt on Facpey MalNeparre X Other. Full facility shutdown Comments: Primary Generator topped oh line duo to (sully processors Lusa of power retmad full facility, Muldovm of of systema H. Action Taken to Viminale Cause and Prevent Recurrence: (Chock and describe as applicable) X Sierted/resladed T/C& r.nc0ortwbImiv G-7000I1C-33012 Stabilized facility process and operation Compressor I tren depressured Repaired equipment dfHiculties Reduced I Increased inlet gas rales w'iN Competed flare tee0ng Facltity maintenance completed X Coaseted E51 fluctuation I failure X Other. Redertetl fatally Comrembet Rgdartdfaclfiy lnruutling powergenero0on ttabltMsandgae canpressbn Wbine end LA mmpresaoc. 777777777777777-1 Fladag or '❑ necessary for facility operalionsrepairs, upgrades. or feeling procedures ❑ an emergency that threatened tae or property ❑ necessary to Prevention oruilimale recovery Venting Incident Was the volume over 1,000 meet? Yes: ❑ No: ❑ (It Yes, completafomo& contact Environmental Immediately) Flare incident TRUE Did incidentlastfor longer than l hour? Yes ❑+ No ❑ If Yes, fax this report to Environmental whhtn 24 hours at KRU-659.7712 or ALP 8167041607 Did event rause black Smoke 13 minutes In i hr or 6 consecutive minutes? Yes: ❑ No: ❑+ If Yea) Contact Emdromenlat Immediately KRU 669.7242 or ALP 6704200 and fax this report to Env at KRU-650-7712 or ALP at 6704607 Bleck smoke' emitted from source: (enter tag number and description) Date and time of black smoke' event: From: To: Volume fared which generated black smoke': MSCF `BBLS Deacripuon of steps to minimize emissions: (Sedgon S above) Malarial flared. Gas: x NOLs: Other: General Weather: Air Temperature: +16 dogs Wind Speedlplrecgan: 15 mph from WSW ' Observation by Non-Cedihad Visible Emissem Observer Based on Icwmagon and belief formed after reasonable Inquiry. I really that the statement. and Information in and attached to this dowmeni are true, eccurale and complete. III Facility Supervisor Date co: Aping Field Environmental Compliance Coordinators, ALP-14 Vw mk: Field Enviwnmentel Com 6ertce Goadmelora, NSK- 61 V Rats flue eesllepodpomeas (nota GAS FLARING or VENTING REPORT - CONOCOPHILLIPS ALASKA, INC. FACILITY: Alpine AIR PERMIT NUMBER: AO0489TVP01 GAS DISPOSITION baleofoeemrence: 118/2016 ❑+ them - ❑vent Time of occurrence: (mmlddlyy) (Chuck Selection) LIM 24:00 "Mtn From: 12:37 To: 44:43 0206 Total Volume Flared or Vented: 3326 MfiCF BBLS Fmm: 16:10 To: ta_34 04A4 Planned ❑ Unplumbed ID From: To: _ Fmm: To: �— Motor No: MTR•35011 (By Facllity) Total Minima Flared or Vented A 0650 (includes volume flared which generated black smoke, 0 applicable) A. Oeeedpllon of Incident and Dauer: (Check as many AS needed to folly dualbe the Indolent) SID T/Ce for X Process lgsalin LOSS of GBneYamr G•70001 TPC SD dee to hlmh eYhnuA mmperalvm section of facility EMERGENCY SHUTDOWN FlartnB for drglsge am4dovm f eladup X Electrical I Inslrumm utum malfunction Flare eyetam leslhg F ss nsu>(denl Inlet gas tales Into facility Faueyarkabwnan Facility Maintenance X Other. FtiladfityalxsMown comments: Ptlmery genwretor tripped o0 line due to faulty processors. Loss of power caused a full facility shutdown of all systema M Action Taken to Eliminate Came and Prevent Recurrence: (Check and describe as appllcabl e) X Started I resigned TIC 9 Rested of Tuminm 0-70001 IC -33(112 Stabilized fac0ty process and operation Compressor I halm depressured Repaired equipment difficulties Reduced l increased Inlet gas rales SAM Completed flare testing Facility maintenance completed X Contacted E&I fluctuation I failure X Dlher. ReMarted facility comments: Diagnostic Checks and Restart of Processora, ftmlad of the ledib Including power ganaralion turbines and Bas comprasaion Wrbltm C. Flaring or Venting was: (Check one) 171 necessary For facility operations, repaim, upgrades, or feeWB procedures ❑ in emergency that Oveatenad life or property ❑ necessary to prevent Jose of ultimate NrxoYajX Ventlng Incldent Was the volume over 1,000 m9ef7 Yes: ❑ No: ❑ (If year, complete form & contact Environmental Immediately) Flare Incldent TRUE Did ineldenllest for longerthan 1 hour? Yes ❑ No ❑ If Yes, fax [his report to Environmental within 24 boom at KRU- 669.7712 or ALP at 6704507 Did event cause black smoks'> 3 minutes In l hr or 6 consecutive minutes? Yes: ❑ No: E) If Vae, }n t E Ir cal lourvaidlaIGIV KRU 659-7242 or ALP 67CA200 and fax ibis reporl Env at KRU-669-7712 or ALP at 67CABOT Black smoke- emitted from source: (enter tag number and description) Data and time of black smoke' event From: To: Volume flared which generated black smoke-: MSCF _BELS Descripllon of steps to minimize emissions: (Section B above) Malarial flared; Gas: X NGLs, Other: General Weather: Air Temperature: +10 Wind SpeadlDirncllon: Is mph from WSW 'Observatlon by Non-Ceslifled Vlslble Emission Observer Based on information and bellef formed after reasonable inquiry. I certify that the statements and information In and attached W this document are hue, accurate and complete. /fJ� Facility Supervisor Date I to ox Alpine: Field Environmental Compliance Coordinators, ALP -14 Ku murk* Field Environmental Compliance Coordinators NSK-61 RP nare2ote• Fkre mss MPert Fortn.4s 1r12a16 Rev 1. 12 May 16 STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1030000017 2. Facility Name Colville River Unit Processing Facility 3. Field Colville River Unit 4. Operator CONOCOPHILLIPS ALASKA, INC. 5. MonthNear of Disposition February -16 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 40,966 Pool Name Pool Code Percent 7. Reinjected 1,556,684 ALPINE 120100 61.1% FIORD 120120 34.4% 8. Flared or vented 1 hour or less 888 NANUQ 120175 3.1 NANUQ-KUPARUK 9. Flared or vented more than 1 hour (see instr.) 0 QANNIK 120180 1A OTHER 10, Pilot and Purge 12'720 11. Assist Gas 100.0% 12. Fuel gas used in lease operations. 445,632 13. Other (see instructions) Official Use Only Authorization >l hr: Safety MCF 74. TOTAL VOLUME (ITEMS 6-13) 2,056,890 Lease Use MCF 15. NGL Gas Equivalent Conservation MCF 16. Purchased gas Waste: MCF 17. Transferred from. 18. Transferred to: (Express as a negative #) Commissioner Date 19. Remarks: Gas sold to Alpine Transportation Company =27,315 Gas gifted to Village of Nuiqsut =13,651 1 hereby certify that the foregoing is true and correct to the best of my knoviedge. 7 Signature. ` ��A �� Title: Revenue & Regulatory Analyst Note: All volumes must be corrected to pressure of 14.65 psia and to a temperature of 600F. Authohty 20 AAC25.235. Printed Name: Diane Hendrickson Phone. 918-661-7897 Date: May 20, 2016 Form 10-422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate Rev 1. 12 May 16 CONOCOPHILLIPS ALASKA, INC CONSERVATION ORDER NO. 443 ALPINE ALPINE PROCESSING FACILITY GAS FLARING INCIDENTS Feb -16 END PLANNED VOLUME DATE TIME DATE TIME UNPLANNED (MSCF) DESCRIPTION OF FLARING EVENT ACTION TAKEN TO MINIMIZE VOLUME Total Flare > 1 Hour 0 Total Flare <= 1 Hour 888 Pilot and Purge 12,720 Total Flare 13,608 STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1030000017 2. Facility Name Colville River Unit Processing Facility 3. Field Colville River Unit 4. Operator CONOCOPHILLIPS ALASKA, INC. 5. Month/Year of Disposition February -16 Disposition Volume MCF 20. Forproducfion from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 40,966 Pool Name Pool Code Percent 7. Reinjected 1,556,684 ALPINE 120100 61.5% FIORD 120120 34.1% 8. Flared or vented 1 hour or less 888 NANUQ 120175 3.1% NANUQ-KUPARUK 9. Flared or vented more than 1 hour (see instr.) 0 QANNIK 120180 1.4% OTHER 10. Pilot and Purge 12,720 11. Assist Gas 100.0% 12. Fuel gas used in lease operations. 445,632 13. Other (see instructions)^ r Official Use Only "s >1 hp _ f sy wr r-. rty.., `.'-a MCF 14. TOTAL VOLUME (ITEMS 6-13) 2,051,890 se Use - MCF 15. NGL Gas Equivalent Conservation MCF 16. Purchased gas Waste: MCF 17. Transferred from: 18. Transferred to: (Express as a negative #) Commissioner Date 19. Remarks: Gas sold to Alpine Transportation Company = 27,315 Gas gifted to Village of Nuiqsut =13,651 1 hereby certify that the foregoing is true and correct to the best of my knovAedge. Diane Hendrickson Signature: 2016.03.1613:18:59-05'00' Title: Revenue 8 Regulatory Analyst Note: All volumes must be corrected to pressure of 14.65 psia and to a temperature of 60°F. Authority20 AAC25.235. Printed Name: Diane Hendrickson Phone: Date. Form 10422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate START END DATE TIME DATE TIME Total Flare > 1 Hour Total Flare r_ 1 Hour Pilot and Purge Total Flare CONOCOPHILLIPS ALASKA, INC CONSERVATION ORDER NO. 443 ALPINE ALPINE PROCESSING FACILITY GAS FLARING INCIDENTS Feb -16 PLANNED VOLUME UNPLANNED IMSCFI DESCRIPTION OF TAKEN TO MINIMIZE VOLUME 0 888 ER ED, s �- 12,720 S 13,608 Rev 1. 12 May 16 STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1030000017 2. Facility Name Colville River Unit Processing Facility 3. Field Colville River Unit 4. Operator CONOCOPHILLIPS ALASKA, INC. 5. MonthNear of Disposition March -16 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 42,798 Pool Name Pool Code Percent 7. Reinjected 1,997,330 ALPINE 120100 61.9% FIORD 120120 34.1 8. Flared or vented 1 hour or less 4,797 NANUQ 120175 2.8% NANUQ-KUPARUK 9. Flared or vented more than 1 hour (see instr.) 0 QANNIK 120180 1.1 OTHER 10. Pilot and Purge 16,458 11. Assist Gas 00.0 12. Fuel gas used in lease operations. 493,423 13. Other (see instructions) Official Use Only Authorization >1 hr'. Safety MCF 14, TOTAL VOLUME (ITEMS 6-13) 2.554.806 Lease Use MCF 15. NGL Gas Equivalent Conservation MCF 16. Purchased gas Waste. MCF 17. Transferred from: 18. Transferred to: (Express as a negative #) Commissioner Date 19. Remarks: Gas sold to Alpine Transportation Company =28,392 Gas gifted to Village of Nuiqsut =14,406 1 hereby certify that the foregoing is true and correct to the best of my knowledge, Note: All volumes must be corrected to Signature: '� �� Title: Revenue & Regulatory Analyst pressure of 14.65 psia and to a temperature of 60°F. Authority 20 Printed Name: Diane Hendrickson Phone: 918-661-7897 Date: May 20, 2016 AAC25.235. Form 10-422 Rev. 512009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate Rev 1. 12 May 16 CONOCOPHILLIPS ALASKA, INC CONSERVATION ORDER NO. 443 ALPINE ALPINE PROCESSING FACILITY GAS FLARING INCIDENTS Mar•16 START END PLANNED VOLUME DATE TIME DATE TIME UNPLANNED (MSCF) DESCRIPTION OF FLARING EVENT ACTION TAKEN TO MINIMIZE VOLUME Total Flare > 1 Hour 0 Total Flare <= 1 Hour 4,797 Pilot and Purge 16,458 Total Flare 21,255 STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1 0300 0001 7 2. Facility Name Colvine River Unit Processing Facility 3. Field Colville River Unit 4. Operator I CONOCOPHILLIPS ALASKA, INC. 5. MonitVYear of Disposition March -16 Disposition Volume MCF 20. Forproouction from muihple PODIA, list COntrfbutiOn Of each pool as a percent of Total Volume. 6. Sold 42,798 Pool Name Pool Code Percent 7. Reinjected 1,997,330 ALPINE 120100 62.1%a FIORD 120120 34.0% 8. Flared or vented 1 hour or less 4,797 NANUQ 120175 2.8% NANUQ-KUPARUK 9. Flared or vented more than 1 hour (see instr.) 0 QANNIK 120180 1.1% OTHER 10. Pitot and Purge 16.458 11. Assist Gas 100.0% 12. Fuel gas used in lease operations. 493,423 13. Other (see Instructions) irin.,i pix fig-�i III�(�Il, ii(, rttiifRbi013�1�� il��9i1 n.� lll�l�I�i'i�i�JWill: lti if Authoriraoon>1 hr. MCF 14. TOTAL VOLUME (ITEMS 6-13) 2,554,806 r"se Use15. MCF NGL Gas EquivalentMCFrvatan 16. Purchased gas Waste: MCF 17. Transferred from: '^ v 18. Transferred to: (Express as a negative #) Commi ione . Date - 19. Remarks: Gas sold to Alpine Transportation Company = 28,392 Gas gifted to Village of Nuiqsut =14,406 I hereby certify that the foregoing is true and correct to the best of my knowledge -Note: Signature: "[�iG Title: Revenue & Regulatory Analyst All volumes must be corrected to pressure of 14.65 psia and to a temperature of 60°F. Authority 20 AAC25.235. Printed Name: Diane Hendrickson Phone: Date: Form 10+422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit In Duplicate CONOCOPHILLIPS ALASKA, INC CONSERVATION ORDER NO. 443 ALPINE ALPINE PROCESSING FACILITY GAS FLARING INCIDENTS Mar -t6 START END PLANNED VOLUME DATE TIME DATE TIME UNPLANNED (MSCF) DESCRIPTION OF FLARING EVENT ACTION TAKEN TO MINIMIZE VOLUME Total Flare > 1 Hour 0 Total Flare <=1 Hour 4,797 Pitot and Purge 16,458 .fig�yyONs.[ Y Total Flare 21,255 ;""' , STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. FacilityNumber2. 103000OD17 Facility Name Colville River Unit Processing Facility 3. Field 14 Colville River Unit Operator CONOCOPH ILLIPS ALASKA, INC. 5. MonthfYear of Disposition Ap61-16 Disposition Volume MOF 20. For production from multiple pools, list contrtildlon of each pool as a percent of Total volume. 6. Sold 41,052 Pool Name Pool Code Percent 7. Reinjected 2,037,096 ALPINE 120100 672% FIORD 120120 28.9°% 8. Flared or vented 1 hour or less 9,145 NANUQ 120175 2.7% NANUO-KUPARUK 9. Flared or vented more than 1 hour (see instr.) 19,212 QANNIK 120180 1.2% OTHER 10. Pilot and Purge 16,707 11. Assist Gas 00.0% 12. Fuel gas used in lease operations. 465,929 13. Other (see instructions) Of9clal UserOhly Authorization >1 hr: Safety MCF td. TOTAL VOLUME (ITEMS 6-13) 2,591,147 Lease'Use MCF 15. NGL Gas Equivalent Conservation MCF V'T &111 1,4 16. Purchased gas Waste: MCF 17. Transferred from: �_ � -z -l6 Commissioner Date 18. Transferred to: (Express as a negative i0 19. Remarks: Gas sold to Alpine Transportation Company = 28,778 Gas gifted to Village of Nuiqsut =12,274 1 hereby certify that the foregoing Is true and correct to the hest of my knowledge. Note: All volumes must be corrected to Signature: /l.rC//'[Title: Revenue & Regulatory Analyst pressure of 14.65 psia and to a temperature of 60 OF. Authority 20 Printed Name: Diane Hendrickson Phone: Date: May 20, 2016 AAC25.235. Form 10-422 Re, 5(20D9 INSTRUCT70N5 ON REVERSE SIDE Submit in Duplicate CONOCOPI nnll ALASR INC CONSERVATION ORDER W. da0 At➢M At -PINE PROCESSING FACILRY GAS FlAIIING INCIDENTS All. Plnraep wwnE OMMbIIB 14:36 011IMS16 Sloe Planned Saw MHdo wne_fDt-t5 waa 1m Mak eanugh Pntluden Testing Cm'lfi we renal she In kr a mhimum of M Jaye ba SerXee m enemm[ Y In v llmJe be use NsuppN M1ra Pa m an, YanaemgeawI bukup m delamne [mrMxhun M9e MIAMI 0000WIMM6 IM pinned 177, One Hall- .MI-15weaM ESA hpm a, Tanana CM -16 VTrenem Mm Y br a mb,I a Se deye I. SeMneelo 0emrmine IIder wsl[aNEe realm appy I peaa to tleW.d presort buMVp In ddvmine rM1ereMrMbu1M MM3 Ye }array erepeMed Atm wp M1 rw reaompkbd in M HBe Mm. COLAS wee M ad beak ft.*Prudence Tear, SaI In a... — P M wel seue breed o wSply Nal an, mlh. ftme CeMnl FwSry drip a bWlyeR enrd. AMdrynpelaglea Rlwmdm+rbnumpwMM.&Intheear, TM CD1.15 M+btlxee cempkhd an Opr023M,]%B. 01461%6 ODDO MfA4%6 1613 pYnnM a29 lInn mle".C,I-1gpraved iaealery =45 all renal, deft m be minimum IN30 aryl fare 41 3defs fImeletl TIv rap dry a FrnYtl In, 13 d vp ml Immerses narYp. CDI-t5 wY ads bvaFRPraanemOdp bademaadaalertlbatme b eWpNb4M Mq*d'x>Qema9eaped+clonremq eMePiwMb resdnv. mdwddfII bwbaWtl feremeaInlnel,192 MMCaMfM SCP of III pea wa erttl over M rtoxben d+anG And I]-9,41116. CID t -16Y a lameay dependedNpee well eat seas ree nplemeN me Halo uM. CD1-15wnnmsed bookProdraen Tramp Eadmnm detmml,e FM Wlwdd be. adiam appyOW gra m M Pbl»Cmhal Fanelydrtlngatle[haart ewN.ApNym per}anra rbaannalkbramnpHe Nev+dlaaan bwBe.W.WWngmr me CDt-1l NMNdtwn [mnplelM en HmA 23d.201fi. Od214O16 03:16 011214016 b9g Planned 38BD inward AeNpmYMrvwsubmkmamMwm,Ndapdewd. CD1'1fiwAremledpinMemHmum N30 deer be TAa aesdy e0wnamrf3 drys INlamear--Cp1-16aw atle ue CUYuym Mvmia °1^n°I°YeMa ellAe m gpdy MpM1a Mn aW<I(a[edOnprodlSmleln. eKN1,192 new, naweU. a n ansAkd 1p,Me[k Mt wed adYewd ever a drys. In m6i,1 g3 pas wsa 6detlewM non9edsexaPdetl MA 17. 2MrpmMeed 173],1%6. 0151-16 Y S Mmelryeupenaed AlpBa wN M1»anwmpMedF meMW end CO1-15wlbwMeaMdreWl PmdwYm TeNp Senaam dalmminv MlM wen asJdbewMtp ¢pd/NtlpnmM Aqa cMMFtl6y dvlg egMaartfeM.A Vldrylm parlpApa dgwmkrydtonwmpnsm Mwep AvwheMI n,,nen 1M1e W1-16 fcnbmFws mrrplalq pea AM 2M 2216. Wll2pp16 00:00 peR1l2%8 23Rd gametl a019 Mad broad M1mp Mennwawen6mlpetlbMMlq Yndapprpw6 CDV$ ramal, flea In M• amenlnagM days Me espyshored1pe12 dapd bdmlMPegaa bultlgmde0amine tlnneMrYlle reale s"factAsap.CDM!masale Ib dallybpM1n Smkean—dpnga 1. vI ralaaM. n MOF0 ndankaM ve alp rIrsM,mN tiI192d mil,aA revereaap.ln Stand 9149,E dRodMd Pawa6nfd owrM IDWeW ..a And 1740,ID1e. COI -13 fa a memory aapepa d ApM M that wn remmpY2M N M WIO PM. CO1-t! a s bwM N&Areau h fthenA TaWq S.M. bddnnl,e 11 M end fall Mranel le sunny Wl Sabal AIWA Cmdal I daft a bYdffirt Ort AlMery re pymmla MCD}-i560winU —1lweremenead winalli6 W,4 014L]%6 160] Plae" M rm wekwr b eeefne` ems eel, Mh ILII .ebwep ler vanatlAelingle mwasmmtleaeaesem aM apps.M was nmpeddenppq 22N,2%6. in lwenlnMum a,A 231, fad CM-14'ell tepmde nhinaeantudapeelYb TM randy Mewed Id 13 dap elYaaeBM MlpCpl-'s. awn m porgy Myr man anaawmapa lw4 lmnn;me'ddbwetib aaN°P ane@efita lTMYfk MI wa.eAWea.6 dap In mal,192 MMBCF INpedretl pawn AaM fvde bwbeekeneeAdApl .'anew a t boa 19212 lennF ,a—,. A1N Nand". 15,707 1.,19 a d.Od STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1030000017 12. Facility Name Colville River Unit Processing Facility 3. Field Colville River Unit 4. Operator CONOCOPHILLIPS ALASKA, INC. 5. Month/Yearcf Disposition May -16 Disposition Volume MCF 20. For production from multiple Pools, list contribution of each pool as a percent of Total Volume. 6. Sold 37,873 Pool Name Pocl Code Percent T Reinjected 1,947,836 ALPINE 120100 71.3% FIORD 120120 23.2% B. Flared or vented 1"hour or less 6,648 NANUQ 120175 3.3°/n NANUQ-KUPARUK 120100 09% 9. Flared or vented more than lhour (see Instr.) QANNIK 120180 1.2%.) OTHER 10. Pilot and Purge 15'972 11. Assist Gas 00.0% 12. Fuel gas used in lease operations. 446,031 13. Other (see instructions) , OfAcial Use OIW' 3, ) I" d"t�."s�. ': ` Authorization al hr. Safety MCF 14. TOTAL VOLUME (REMS 6-13) 2,454,360 Lease Use MCF 15. NGL Gas Equivalent Conservation MCF 16. Purchased gas waste: MCF 17. Transferred from. 16. Tranafeffed l0: (Express a5 a negative ih Commissioner Dale 19. Remarks: Gas sold to Alpine Transportation Company = 29,348 Gas gifted to Village of Nuiqsut =8,525 1 hereby certify that the foregoing s'.rue and correct to the best of my knowledge. ` Note: All volumes must be corrected to Signature: Title: Revenue a Regulatory Analyst pressure of 14.65psia and to a temperature of 60°F. Authority20 Printed Name: Diane Hencinckson Phone: Date: June 20, 2016 AAC25.235. Form 10322 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE CONFIDENTIAL pursuant to: AS 43.05.230, AS 40.25.1Q0. AS 38.05.035 (a)(8), and AS 38.05.036 (f). Submitin Duplicate CONOCOPHILLIPS ALASKA, INC CONSERVATION ORDER NO. 443 ALPINE ALPINE PROCESSING FACILITY GAS FLARING INCIDENTS May -16 DATE START TME DATE END TIME PLANNED UNP.ANNm VOLUME MSC DESCRIPnON OF FLARING EVENT ACTION TMEN TO MININREVCUIME TMIFV»Il Neu, D Tdel FLre a 1 Hwr ®,644 Pilo end P.r ls.m T.W R. 2 .Wo STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1030000017j&1 2Facility Name ville River Unit Processing Facility 3. Field Colville River Unit 4. Operator CON0 OPHILLIPS ALASKA, INC, 5. MonthNear of Disposition June -16 Disposition Volume MCF 20. Forproduction from mulhple pools, list contribution of each pool as a percent or Total Volume. 6. Sold 36,808 Pool Name Pool Code Percent 7. Reinjected 1 479 814 ,, ALPINE 120100 FIORD 120120 24.0% 8. Flared or vented 1 hour or less 75,050 NANUQ 120175 3.2% NANUQ-KUPARUK 120100 0.4% 9. Flared or veined more than 1 hour (see insb.) 2,112 QANNIK 120180 1.3% OTHER 120180 0.5% 10. Pilot and Purge 17'429 11. Assist Gas 100.0% 72. Fuel gas used In lease operations. 414,886 73. Other (see instructions) I •.. i.:. lficlallU,sdf11 -i . ✓r " _ _ `MCF Authorization >1 hr. Safety 14. TOTAL VOLUME (ITEMS 6.73) 2,299,764 Lease Use MCF 15, NGL Gas Equivalent Conservation z Z MCF VT1- 16. Purchased gas Warta: MCF 17. Transferred from: 18. Transferred to: (Express as a negative lq Commissioner Date 19. Remarks: Gas sold to Alpine Transportation Company = 28,772 Gas gifted to Village of Nuigsut =7,036 1 hereby certify that the foregoing is true and correct to the best of my knowledge. • Note: All volumes must be corrected to Signature: True: Revenue & Regulatory Analyst pressure of 14.65 Asia and to a temperature of 60°F. Authority 20 Printed Name: Diane Hendrickson Phone: Date: July 20, 2016 AAC25.235. Form 30-422 Rev. 512009 INSTRUCT DNS ON REVERSE SIDE Submit In Duplicate C CONOCOPHILLIPS ALASKA, INC CONSERVATION ORDER NO, 443 ALPINE ALPINE PROCESSING FACILITY GAS FLARING INCIDENTS Jun•16 START END PLANNED VOLUME DATE nue nenc Tore) He. 1Hftr 2,112 roral Flare w 1 Mour 15,050 Pitt and knVe 17,428 Tafel Flare a4,5el - - -- - -- -- -��• ---•••-v-1—cmn, AV I IVN IPREN TO MMMRE VOLUME 03/071201 B 01:02 0810712018 02:17 UNPLANNED 288 During flowtoack of cues CD&02 back to the ACF as well began to Clean up Ne plan experienced an excesdve gas rete Reduced nate from DDS -02 and shut In well CDI-42 to stop exoessNe gas rate and Mm CD1-13 is a formerly suspended Alpine web that was mcompletedN 0822!/018 2228 08/21/2078 23:43 PLANNED 351 the Hat sand. A sundryto perform a rig workover to recamplete In$ well, with a 8owback bet aiming for increased flaring tolerances was submitted to me state, and approved An Isochnmal flovnest was executed t tear the wall's deliveraWlBy, The 4 stage Ilowtest was executed from June 20-24. In local, 1,0 MMSCF of gas was flared during reportaole flaringevents tmelph CD1-13s 8owback stages The C01-15 gawlealwes completed on June 24th, 2076. Since a new awyafaca safety valve was June241h. 2 16 o 1- 16 after the completion of the flowtest, the wet will need to be flowed to perform state -witnessed function Losing of the saley valve system. executed June 20.24, 08242018 07:32 08/26/2078 05:35 PLANNED 1112 Sema as above Same as shave 081242016 08:43 05/1,112018 08:06 PIAN NED 380 Same as above Same as above Tore) He. 1Hftr 2,112 roral Flare w 1 Mour 15,050 Pitt and knVe 17,428 Tafel Flare a4,5el STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1030000017 2. Facility Name Colville River Unit Processing Facility 3. Field Colville River Unit 4. Operator CONOCOPHILLIPS ALASKA, INC. 5. Month/Year of Disposition July -16 Disposition Volume MCF 20. Forproduction from multiple pools, list contribution ofeach pool as a percent of Total Volume. 6. Sold 22,013 Pool Name Pool Code Percent 7. Reinjected 1,149,335 ALPINE 120100 65.53/. FIORD 120120 26.5% 8. Flared or vented 1 hour or less 7,420 NANUQ 120175 3.8% NANUQ-KUPARUK 120100 0.7% 9. Flared or vented more than 1 hour (see instr.) 0 QANNIK 120180 1.47/6 OTHER 120180 2.2% 10. Pilo[ and Purge 8,638 11. Assist Gas 100.0% 12. Fuel gas used in lease operations. 282,252 13. Other (see instructions) Official Use Only Authorization >1 hr Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 1,469,658 Lease Use MCF 15. NGL Gas Equivalent Conservation MCF 16. Purchased gas Waste: MCF 17. Transferred from: 18. Transferred to: (Express as a negative #) Commissioner Date 19. Remarks: Gas sold to Alpine Transportation Company = 17,820 Gas gifted to Village of Nuiqsut =4,193 1 hereby certify that the foregoing is true and correct to the best of my knowledge. 7� Signature: T�Ga/r.Q. Qi�/7i Title: Revenue 8 Regulatory Analyst Note: All volumes must be corrected to pressure Of 14.65 Asia and to a temperature of 60°F. Authotity 20 AAC25.235. Printed Name: Diane Hendrickson Phone: Date: August 20, 2016 Form 10-422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate CONOCOPHILLIPS ALASKA, INC CONSERVATION ORDER NO. 443 ALPINE ALPINE PROCESSING FACILITY GAS FLARING INCIDENTS Jul -16 Total Flare > 1 Hour 0 Total Flare <=1 Hour 7.420 Pilot and Purge 8.638 Total Flare 16,058 ConocoPhillips ConocoPhillips Alaska, Inc. P.O. Box 100360 Anchorage, Alaska 99510-0360 August 18, 2016 TO: Recipients of the Colville River Unit Participating Area Monthly Production Report of Gas Disposition Enclosed is the Produced Gas Disposition Report for July 2016. Please address any questions to Diane Hendrickson at (918) 661-7897. Sincerely, Diane Hendrickson Revenue and Regulatory Analyst Enclosures STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1030000017 2. Facility Name Colville River Unit Processing Facility 3. Field Colville River Unit 4. Operator CONOCOPHILLIPS ALASKA, INC. 5. MonthlVear of Disposition August -16 Disposition Volume MCF 20. Forproduction from multiple pools, list contribution of each pool as a percent of Total volume. 6. Sold 31,530 Pool Name Pool Code Percent 7. Reinjected 1,582,703 ALPINE 120100 68.1% FIORD 120120 26.0% 8. Flared or vented l hour or less 5,022 NANUQ 120175 3.5% NANUQ-KUPARUK 120100 0.5% 9. Flared or vented more than 1 hour (see instr.) 2,557 OANNIK 120180 1.6% OTHER 120180 0.2% 10. Pilot and Purge 6,646 11. Assist Gas 99.9 12. Fuel gas used in lease operations. 366,136 13. Other (see instructions) Official Use Only Authorization >t hr: Safety 2 �� MCF Ai fD 14. TOTAL VOLUME (ITEMS 6-13) 1,994,594 Lease Use MCF 15. NGL Gas Equivalent Conservation MCF 16. Purchased gas Waste: MCF 17. Transferred from:(Z �/ 18. Transferred to: (Express as a negative #) Commissioner Date 19. Remarks: Gas sold to Alpine Transportation Company = 25,151 Gas gifted to Village of Nuiqsut =6,379 1 hereby certify that the foregoing is true and correct to the best of my knovAedge. Signature: ��'N'� �� Title: Revenue 8 Regulatory Analyst Note: All volumes must be corrected to pressure of 14.65 psia and to a temperature of 60°F. Authority 20 AAC25.235. Printed Name: Diane Hendrickson Phone: Date: September 20, 2016 Form 10-422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate 11 CONOCOPHILLIPS ALASKA, INC CONSERVATION ORDER NO. 443 ALPINE ALPINE PROCESSING FACILITY GAS FLARING INCIDENTS AuR 16 END PLANNED VOLUME Tue. nATF TUF I.....NNF. IMSCFI nFSCRIPTIGN OF FLARING EVENT ACTION TAKEN TO MINIMRE VOLUME Restart activities follovdng 14 day Plant Turnaround. Flared while nd SI of weAs; Operations restartetl gas pain operations 08/05/2016 0718 08/052016 14:31 UNPLANNED 2557 attempting to get gas train and compressors restarted; had difficulties aand restarted gas er ti LP compressors G33012 & C - with instrumentation on LP Compressor C-32012. Total From >1 Hour 2,557 Total Flare � 1 Hour 5022 Pi/otan4Parge 6.646 Total Flare 14,325 ConocoPhillips ConocoPhillips Alaska, Inc. P.O. Box 100360 Anchorage, Alaska 99510-0360 Enclosures September 20, 2016 TO: Recipients of the Colville River Unit Participating Area Monthly Production Report of Gas Disposition Enclosed is the Produced Gas Disposition Report for August 2016. Please address any questions to Diane Hendrickson at (918) 661-7897. Sincerely, Diane Hendrickson Revenue and Regulatory Analyst Enclosures STATE OF ALASKA ALASKA OIL AND GAS CONSERVATION COMMISSION FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1030000017 12. Facility Name Colville River Unit Processing Facility 3. Field Colville River Unit 4. Operator 5. Month/Year of Disposition CONOCOPHILLIPS ALASKA, INC. September -16 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 36,059 Pool Name Pool Code Percent 7. Reinjected 1.616,341 ALPINE 120100 67.2% FIORD 120120 27.7% 8. Flared or vented 1 hour or less 3,439 NANUQ 120175 3.2% NANUQ-KUPARUK 120100 0.6% 9. Flared or vented more than 1 hour (see instr.) 0 QANNIK 120180 1.3% OTHER 120180 0.0% 10. Pilot and Purge 6.292 11. Assist Gas 00.0% 12. Fuel gas used in lease operations. 420,540 13. Other (see instructions) Official Use Only Authorization>1 hr Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 2,082,671 Lease Use MCF 15. NGL Gas Equivalent Conservation MCF 16. Purchased gas Waste: MCF 17. Transferred from: 18. Transferred to: (Express as a negative #) Commissioner Date 19. Remarks: Gas sold to Alpine Transportation Company = 28,384 Gas gifted to Village of Nuiqsut =7,675 1 hereby certify that the foregoing is true and correct to the best of my knowledge. /e��/ Signature: f/), ,.L Q.N�iii Title: Revenue & Regulatory Analyst Note: All volumes must be corrected to pressure of 14.65 psla and to a temperature of 60°F. Authority 20 AAC25.235. Printed Name: Diane Hendrickson Phone: Date: October 20, 2016 Form 10-422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate CONOCOPHILLIPS ALASKA, INC CONSERVATION ORDER NO.443 ALPINE ALPINE PROCESSING FACILITY GAS FLARING INCIDENTS Sep -19 PLANNED VOLUME Tab/ F/are> 1 Hour 0 Tobl Flare <=1 Hour 3.439 Pitt and Purge 6,292 Tmal Flare 9,731 ConocoPhillips ConocoPhillips Alaska, Inc. P.O. Box 100360 Anchorage, Alaska 99510-0360 October 20, 2016 TO: Recipients of the Colville River Unit Participating Area Monthly Production Report of Gas Disposition Enclosed is the Produced Gas Disposition Report for September 2016. Please address any questions to Diane Hendrickson at (918) 661-7897. Sincerely, Diane Hendrickson Revenue and Regulatory Analyst Enclosures STATE OF ALASKA nin FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1030000017 2. Facility Name Colville River Unit Processing Facility 3. Field Colville River Unit 4. Operator CONOCOPHILLIPS ALASKA, INC. 5. Month/Year of Disposition October -16 Disposition Volume MCF 20. Far production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 37,757 Pool Name Pool Code Percent 7. Reinjected 1,845,654 ALPINE 120100 58.8% FIORD 120120 36.2% 8. Flared or vented 1 hour or less 4,924 NANUO 120175 3.4% NANUO-KUPARUK 120100 0.6% 9. Flared or vented more than 1 hour (see instr.) 0 OANNIK 120180 1.1% OTHER 120180 0.0 10. Pilot and Purge 7,611 11. Assist Gas 100.0 12. Fuel gas used in lease operations. 446,214 13. Other (see instructions) Official Use Only Authorization >1 hr Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 2,342,160 Lease Use MCF 15. NGL Gas Equivalent Conservation MCF 16. Purchased gas Waste. MCF 17. Transferred from: Commissioner Date 18. Transferred to: (Express as a negative #) 19. Remarks: Gas sold to Alpine Transportation Company = 28,222 Gas gifted to Village of Nuiqsut =9,535 1 hereby certify that the foregoing is true and correct to the best of my knowledge. Signature: �� Title: Revenue & Regulatory Analyst Note: All volumes must be corrected to pressure of 14.65 psia and to a temperature of 60°F. Authority 20 AAC25.235. Printed Name: Diane Hendrickson Phone: Date: November 20, 2016 Form 10-422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate CONOCOPHILLIPS ALASKA, INC CONSERVATION ORDER NO. 443 ALPINE ALPINE PROCESSING FACILITY GAS FLARING INCIDENTS Oct -15 Total Flom> 1 Hour Total Flare <= f Hour 4.824 Pilot and Purge 7.611 Total Flare 12,535 ConocoPhillips ConocoPhillips Alaska, Inc. P.O. Box 100360 Anchorage, Alaska 99510-0360 November 20, 2016 TO: Recipients of the Colville River Unit Participating Area Monthly Production Report of Gas Disposition Enclosed is the Produced Gas Disposition Report for October 2016. Please address any questions to Diane Hendrickson at (918) 661-7897. Sincerely, Diane Hendrickson Revenue and Regulatory Analyst Enclosures STATE OF ALASKA nin FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 103000001 7 2. Facility Name Colville River Unit Processing Facility 3. Field Colville River Unit 4. Operator CONOCOPHILUPS ALASKA, INC. 5. Month/Year of Disposition November -16 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume, 6. Sold 37,802 Pool Name Pool Code Percent 7. Reinjected 1,843,043 ALPINE 120100 FIORD 120120 38.8% 8. Flared or vented 1 hour or less 359 NANUQ 120175 2.8% NANUQ-KUPARUK 120100 2.7% 9. Flared or vented more than 1 hour (see instr.) 0 QANNIK 120180 1.0% OTHER 120180 0.0% 10. Pilot and Purge 4,698 11. Assist Gas 100.0% 12. Fuel gas used in lease operations. 453,351 13. Other (see instructions) Official Use Only Authorization>1 hr: Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 2,339,253 Lease Use MCF 15. NGL Gas Equivalent Conservation MCF 16. Purchased gas Waste: MCF 17. Transferred from: Commissioner Date 18. Transferred to: (Express as a negative #) 19. Remarks: Gas sold to Alpine Transportation Company = 27,018 Gas gifted to Village of Nuiqsut =10,784 1 hereby certify that the foregoing is true and correct to the best of my knowledge. � Note: All volumes must be corrected to Signature: Title: Revenue & Regulatory Analyst pressure of 14.65 psia and to a temperature of 60OF. Authority 20 Printed Name: Diane Hendrickson Phone: Date. December 20, 2016 AAC25.235. Form 10-422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate CONOCOPHILLIPS ALASKA, INC CONSERVATION ORDER NO. 443 ALPINE ALPINE PROCESSING FACILITY GAS FLARING INCIDENTS Nov -16 Total Flare > 1 Hour Total Flare o 1 Hour 359 Flbtaa4Wrge 4.698 Total Flare 5.057 ConocoPhillips ConocoPhillips Alaska, Inc. P.O. Box 100360 Anchorage, Alaska 99510-0360 December 20, 2016 TO: Recipients of the Colville River Unit Participating Area Monthly Production Report of Gas Disposition Enclosed is the Produced Gas Disposition Report for November 2016. Please address any questions to Diane Hendrickson at (918) 661-7897. Sincerely, Diane Hendrickson Revenue and Regulatory Analyst Enclosures STATE OF ALASKA nin FACILITY REPORT OF PRODUCED GAS DISPOSITION 1. Facility Number 1030000017 2. Facility Name Colville River Unit Processing Facility 3. Field Colville River Unit 4. Operator 5. Monthlyear of Disposition ICONOCOPHILLIPS ALASKA, INC. December -16 Disposition Volume MCF 20. For production from multiple pools, list contribution of each pool as a percent of Total Volume. 6. Sold 42.381 Pool Name Pool Code Percent 7. Reinjected 1,778.580 ALPINE 120100 577/6 FIORD 120120 35.1 8. Flared or vented lhour or less 262 NANUQ 120175 2.8% NANUQ-KUPARUK 120100 3.4% 9. Flared or vented more than 1 hour (see instr.) 0 QANNIK 120180 0.9% OTHER 120180 0.0% 10. Pilot and Purge 4,861 11. Assist Gas 100.0% 12. Fuel gas used in lease operations. 494,491 13. Other (see instructions) Official Use Only Authorization 11 hr: Safety MCF 14. TOTAL VOLUME (ITEMS 6-13) 2,320,575 Lease Use MCF 15. NGL Gas Equivalent Conservation MCF 16. Purchased gas Waste. MCF 17. Transferred from: Commissioner Date 18. Transferred to: (Express as a negative #) 19. Remarks: Gas sold to Alpine Transportation Company = 28,427 Gas gifted to Village of Nuiqsut =13,954 1 hereby certify that the foregoing is true and correct to the best of my knovAedge. Signature: �� Title: Revenue & Regulatory Analyst Note: All volumes must be connected to pressure of 14.65 psia and to a temperature of 60°F. Authority 20 AAC25.235. Printed Name: Diane Hendrickson Phone: Date: January 20, 2017 Form 10-422 Rev. 5/2009 INSTRUCTIONS ON REVERSE SIDE Submit in Duplicate