Form BSEE-0143 "Facility/Equipment Damage Report"

What Is Form BSEE-0143?

This is a legal form that was released by the U.S. Department of the Interior - Bureau of Safety and Environmental Enforcement on February 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2018;
  • The latest available edition released by the U.S. Department of the Interior - Bureau of Safety and Environmental Enforcement;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form BSEE-0143 by clicking the link below or browse more documents and templates provided by the U.S. Department of the Interior - Bureau of Safety and Environmental Enforcement.

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Download Form BSEE-0143 "Facility/Equipment Damage Report"

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U.S. Department of the Interior
OMB Control Number: 1014-0022
Bureau of Safety and Environmental Enforcement (BSEE)
OMB Approval Expires: 02/28/2021
FACILITY/EQUIPMENT DAMAGE REPORT
Use this form to submit the damage report required by 30 CFR 250.192. Send completed form via e-mail or telefax within 48 hours after you
complete your initial evaluation of the damage. Submit monthly reports thereafter and immediately whenever damage or estimated return to
service information submitted in previous reports changes. In the final report, provide the date the item was returned to service. Submit the
report to:
GOMR
POCSR
AKOCS
E-MAIL: EVACSTATS@BSEE.gov
E-MAIL: damagereport@bsee.gov
E-MAIL :
TELEFAX: Primary - (504) 736-5796 or
TELEFAX: (805) 389-7592
BSEEAlaskaReports@bsee.gov
(Alternate) - (504) 736-2426
TELEFAX: (907) 334-5302
Or telefax BSEE Headquarters (if the appropriate regional office is closed) - (703) 787-1093
GENERAL INFORMATION
Company name:
Event/Event date:
Contact:
Telephone number:
Report date:
Report time:
Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that BSEE collects this information to
rapidly assess damage and project any disruption of oil and gas supplies from the OCS. Responses are mandatory (43 U.S.C. 1331 et seq.). No proprietary
information is collected. An agency may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a
currently valid OMB Control Number. Public reporting burden for this form is estimated to average 3 hours for the initial response, and estimated to average 1
hour per updated response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You may
direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Bureau of Safety and
Environmental Enforcement, 381 Elden Street, Herndon, VA 20170.
BSEE
Form BSEE-0143 (Feb/2018 - Supersedes all previous versions of this form which may not be used.)
Page 1 of 2
U.S. Department of the Interior
OMB Control Number: 1014-0022
Bureau of Safety and Environmental Enforcement (BSEE)
OMB Approval Expires: 02/28/2021
FACILITY/EQUIPMENT DAMAGE REPORT
Use this form to submit the damage report required by 30 CFR 250.192. Send completed form via e-mail or telefax within 48 hours after you
complete your initial evaluation of the damage. Submit monthly reports thereafter and immediately whenever damage or estimated return to
service information submitted in previous reports changes. In the final report, provide the date the item was returned to service. Submit the
report to:
GOMR
POCSR
AKOCS
E-MAIL: EVACSTATS@BSEE.gov
E-MAIL: damagereport@bsee.gov
E-MAIL :
TELEFAX: Primary - (504) 736-5796 or
TELEFAX: (805) 389-7592
BSEEAlaskaReports@bsee.gov
(Alternate) - (504) 736-2426
TELEFAX: (907) 334-5302
Or telefax BSEE Headquarters (if the appropriate regional office is closed) - (703) 787-1093
GENERAL INFORMATION
Company name:
Event/Event date:
Contact:
Telephone number:
Report date:
Report time:
Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that BSEE collects this information to
rapidly assess damage and project any disruption of oil and gas supplies from the OCS. Responses are mandatory (43 U.S.C. 1331 et seq.). No proprietary
information is collected. An agency may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a
currently valid OMB Control Number. Public reporting burden for this form is estimated to average 3 hours for the initial response, and estimated to average 1
hour per updated response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You may
direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Bureau of Safety and
Environmental Enforcement, 381 Elden Street, Herndon, VA 20170.
BSEE
Form BSEE-0143 (Feb/2018 - Supersedes all previous versions of this form which may not be used.)
Page 1 of 2
FACILITY/EQUIPMENT DAMAGE REPORT
Initial
Production Rate
Cumulative
Facility
OCS
Estimated Time
OCS
Damage
Damage
Damage
at Time of Shut-In
Production Shut-In
Name
Block /
to Return to
Area
Type #
Description +
Assessment
(BPD and/or
(BPD and/or
Lease
Service (days) *
Φ
MMCFPD)
MMCFPD)
◊ If the damaged facility is a pipeline, provide the BSEE pipeline segment number.
# Provide the type of damage (e.g., platform or other facility, production equipment, pipeline).
+ Use separate sheet if needed.
Φ Either major, medium, or minor.
* Need not be provided until availability of hardware and repair capability has been established (not to exceed 30 days from initial report).
CERTIFICATION: I certify that the information submitted is complete and accurate to the best of my knowledge. I understand that making a false statement may subject me to the criminal
penalties of 18 U.S.C. 1001.
Name and Title: ________________________________________
Date: ________________________
BSEE
Form BSEE-0143 (Feb/2018 – Supersedes all previous versions of this form which may not be used.)
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