ALASKA DNR - OIL & GAS V 1.201605 REPORT TYPE (PTLA Report) PT REPORT CODE (NPSL Report) AL FILING TYPE REG CUSTOMER ID NUMBER 000012345 PRODUCTION MONTH 01/01/2016 REVISION NO. 00 REPORT MONTH 03/01/2016 CONTROL NUMBER 000012345N03201600 AUTHORIZED DATE 03/31/2016 123456 LEASE NUMBER DATE OF LESSEE’S FIRST AK OIL OR GAS PRODUCTION 03/01/2012 LESSEE NAME XYZ Company ADDRESS1 Enter Data ADDRESS2 Enter Data CITY Data Enter Data STATE ZIP Data PREPARER Enter Data PREPARER PHONE NUMBER Enter Data PREPARER FAX NUMBER Enter Data AUTHORIZED SIGNATURE (CODE) Enter Data Enter Data AUTHORIZED SIGNATURE (Printed Name) PHONE NUMBER Enter Data FAX NUMBER Enter Data
ALASKA DNR - OIL & GAS V 1.201605 REPORT TYPE (PTLA Report) PT REPORT CODE (NPSL Report) AL FILING TYPE REG CUSTOMER ID NUMBER 000012345 PRODUCTION MONTH 01/01/2016 REVISION NO. 00 REPORT MONTH 03/01/2016 CONTROL NUMBER 000012345N03201600 AUTHORIZED DATE 03/31/2016 LEASE NUMBER 123456 DATE OF LESSEE’S FIRST AK OIL OR GAS PRODUCTION 03/01/2012 LESSEE NAME XYZ Company ADDRESS1 Enter Data ADDRESS2 Enter Data CITY Data STATE Enter Data ZIP Data PREPARER Enter Data PREPARER PHONE NUMBER Enter Data PREPARER FAX NUMBER Enter Data AUTHORIZED SIGNATURE (CODE) Enter Data AUTHORIZED SIGNATURE (Printed Name) Enter Data PHONE NUMBER Enter Data FAX NUMBER Enter Data