OHIO DEPARTMENT OF NATURAL RESOURCES Submit this completed report to DIVISION OF OIL & GAS RESOURCES MANAGEMENT within 30 days of the initial incident report. 2045 Morse Road, F-2 Columbus, OH 43229-6693 • Complete parts A-I for all reportable incidents. Complete parts J-M for reportable pipeline incidents. 30-DAY POST INCIDENT REPORT Rev. 01/17 Report Completion Date: ODNR Incident Number: mm/dd/yyyy EPA Number: NRC Case Number: Part A: Well/Facility Operation Information Authorized Authorized Activity: Person / Choose one Phone: Email: Street Address: / OH / City / State / Zip: Well / Facility Name: Identification Number: Which type of number? Part B: Incident Location, Date, Time, and Weather Conditions Please enter lat/lon in decimal degrees. - Latitude: Longitude: Directions to Location of Incident: Include distance and direction from nearest intersection County: or milepost. Address: Township: City/Village: Cross Streets: MPH Incident Discovery Date: Wind Speed: mm/dd/yyyy Incident Discovery Time: eg. 4:45 pm Wind Direction Duration of Incident: Weather Conditions: days Incident Controlled Date: Amount of Precipitation: mm/dd/yyyy °F Temperature:
OHIO DEPARTMENT OF NATURAL RESOURCES DIVISION OF OIL & GAS RESOURCES MANAGEMENT 2045 Morse Road, F-2 • Columbus, OH 43229-6693 Submit this completed report to within 30 days of the initial incident report. Complete parts A-I for all reportable incidents. Complete parts J-M for reportable pipeline incidents. 30-DAY POST INCIDENT REPORT Rev. 01/17 Report Completion Date: mm/dd/yyyy ODNR Incident Number: EPA Number: NRC Case Number: Part A: Well/Facility Operation Information Authorized Person / Phone: Email: Street Address: City / State / Zip: / OH / Well / Facility Name: Authorized Activity: Choose one Identification Number: Which type of number? Part B: Incident Location, Date, Time, and Weather Conditions Please enter lat/lon in decimal degrees. Latitude: Longitude: - County: Address: Township: City/Village: Cross Streets: Directions to Location of Incident: Include distance and direction from nearest intersection or milepost. Incident Discovery Date: mm/dd/yyyy Incident Discovery Time: eg. 4:45 pm Duration of Incident: days Incident Controlled Date: mm/dd/yyyy Temperature: °F Wind Speed: MPH Wind Direction Weather Conditions: Amount of Precipitation:
DOGRM_30dayReport.docx