Chaparral Energy Safety Related Condition Report

• Facility/Line Segment

• Conducted on

  Date

• Prepared by

• Location
  Address

• Chaparral Instructions:
  
  Production and/or other field personnel must provide all information in Parts 1-6 to the Pipeline Compliance Department.
  
  The Pipeline Compliance Department will report this info to DOT or a required State agency.

• Chaparral Energy
  701 Cedar Lake Blvd.
  OKC, OK. 73114
  405-426-4476

• Date

  Date

Part 1

• Date Discovered

  Date

• Milepost/Stake #

• County

• Location

• City, State

• Product Transported

Part 2

• Determined unsafe by: (include date determined and title if applicable)

Part 3: Type of Condition

• General Corrision

• Unintended Movement or Abnormal Loading

• Equipment Malfunction

• Leak

• Localized Corrosion

• Material Defect or Physical Damage

• Operator Error

• Other

• If "other", please explain

• Comments

Part 4

• Conditions Leading to Discovery:

Part 5

• Corrective Action Taken

Part 6

• Future Action: (include schedule to start and finish)

Part 7

• Signature

  Sign

• Supervisors review

  Sign