Form SSTA (9604) "Site Specific Trust Accounts" - Louisiana

What Is Form SSTA (9604)?

This is a legal form that was released by the Louisiana Department of Natural Resources - a government authority operating within Louisiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Louisiana Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SSTA (9604) by clicking the link below or browse more documents and templates provided by the Louisiana Department of Natural Resources.

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Download Form SSTA (9604) "Site Specific Trust Accounts" - Louisiana

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Form SSTA (9604)
DEPARTMENT OF NATURAL RESOURCES
ESTIMATE OF OILFIELD SITE RESTORATION COSTS
SITE SPECIFIC TRUST ACCOUNTS
Date _______________________
Field Name ____________________________________________________________________Field Code _____________________
Transferor_____________________________________________________________________Operator Code___________________
Transferee_____________________________________________________________________Operator Code __________________
Contractor Performing Assessment________________________________________________________________________________
Contact Person and Phone Number__________________________________________________________________
Well Name*
Well Number
Serial Number
PBTD
Estimated Cost to P&A
$
$
$
$
$
$
Pits Associated with Site*
ID Number
Estimated Cost to Close
$
$
Production Equipment*
Production Equipment
*Attach Addendum if Needed
Total P&A Cost
$_________________
Total Pit Closure Cost
$_________________
Total Equipment Removal Cost
$_________________
Production Platform Removal Cost
$_________________
Underwater Obstruction Removal and Site Clearance Verification Cost
$_________________
Surface Restoration Cost
$_________________
Other Restoration Cost
$_________________
Total Site Restoration Cost (
Attach a detailed explanation of all factors considered in arriving at cost
.
$_________________
estimates, i.e., wellbore schematics, plugging and abandonment procedures, pit closure procedures, etc.)
Method of Funding
(The three acceptable methods include: Cash, Performance Bond, & Letter of Credit. Any other proposed method of funding must be
approved by the Commissioner of Conservation.
______________________________
_____________________________
_______________________
Signature, Transferor
Printed Name
Title
_____________________________
_____________________________
_______________________
Signature, Transferee
Printed Name
Title
FOR OFFICE USE ONLY
______________________________
________________
________________
Approved By
Date
SSTA Acct. No.
Form SSTA (9604)
DEPARTMENT OF NATURAL RESOURCES
ESTIMATE OF OILFIELD SITE RESTORATION COSTS
SITE SPECIFIC TRUST ACCOUNTS
Date _______________________
Field Name ____________________________________________________________________Field Code _____________________
Transferor_____________________________________________________________________Operator Code___________________
Transferee_____________________________________________________________________Operator Code __________________
Contractor Performing Assessment________________________________________________________________________________
Contact Person and Phone Number__________________________________________________________________
Well Name*
Well Number
Serial Number
PBTD
Estimated Cost to P&A
$
$
$
$
$
$
Pits Associated with Site*
ID Number
Estimated Cost to Close
$
$
Production Equipment*
Production Equipment
*Attach Addendum if Needed
Total P&A Cost
$_________________
Total Pit Closure Cost
$_________________
Total Equipment Removal Cost
$_________________
Production Platform Removal Cost
$_________________
Underwater Obstruction Removal and Site Clearance Verification Cost
$_________________
Surface Restoration Cost
$_________________
Other Restoration Cost
$_________________
Total Site Restoration Cost (
Attach a detailed explanation of all factors considered in arriving at cost
.
$_________________
estimates, i.e., wellbore schematics, plugging and abandonment procedures, pit closure procedures, etc.)
Method of Funding
(The three acceptable methods include: Cash, Performance Bond, & Letter of Credit. Any other proposed method of funding must be
approved by the Commissioner of Conservation.
______________________________
_____________________________
_______________________
Signature, Transferor
Printed Name
Title
_____________________________
_____________________________
_______________________
Signature, Transferee
Printed Name
Title
FOR OFFICE USE ONLY
______________________________
________________
________________
Approved By
Date
SSTA Acct. No.
Form SSTA (9604)
ADDENDUM TO FORM SSTA (9604)
Well Name*
Well Number
Serial Number
Total Depth
Estimated Cost to P&A
Pits Associated with Site*
ID Number
Estimated Cost to Close
$
$
$
$
$
Production Equipment*
Production Equipment
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