Form Ogb-21 - Authorization To Clean Tank - State Oil And Gas Board Of Alabama

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STATE OIL AND GAS BOARD OF ALABAMA
OGB-21
Authorization to Clean Tank
Form OGB-21, Rev. 07/13
(File in duplicate)
Name of operator _____________________________________________________________________________________________________
Address _________________________________________ City ________________________ State _______________ Zip _______________
DESCRIPTION OF TANK
Tank name and number _____________________________________________ Tank location ________________________________________
(section, township, range)
Field (if wildcat, so state) _______________________________________________________________ County __________________________
Tank capacity ___________________ bbls Tank height ____________ ft. ___________ in. Sales Outlet height ___________ ft. __________ in.
DESCRIPTION OF CLEANING OPERATION
Gross contents ________________________________________________________________________________________________________
Contents verified by Agent of the Board:
Yes
No
If Yes, give name ____________________________________________________________ Date _____________________________________
Cleaning requested by purchaser:
Yes
No
If Yes, give name ____________________________________________________________ Date _____________________________________
Date cleaning began _________________________________________ Date cleaning completed _____________________________________
Name of transporter ____________________________________________________________________________________________________
Disposition of contents ________________________________________________________ Date ____________________________________
Contents delivered to treating or reclaiming plant:
Yes
No
If Yes, give name of plant _______________________________________________________________________________________________
plant location _______________________________________________________________________________________________
plant contact person ____________________________________________ Phone number ________________________________
Notification to clean tank given to________________________________________________ Date ____________________________________
(Oil & Gas Board Agent)
Date of last cleaning ___________________________________________
Person to contact
Phone number
regarding this form
Fax number
E-mail address
The undersigned certifies that the above-mentioned tank contains only the above amount of gross contents and that no crude oil or product
of crude oil was mixed with, treated of said contents in said tank, or substituted for the tank contents as described above. The undersigned further
certifies that no rule or regulation of the State Oil and Gas Board of Alabama Administrative Code was violated in the cleaning of the tank or in the
transportation of said contents.
Remarks:
__________
________
Executed this the _______ day of __________
, 20 __
___________________________________________________
Signature
________________________________________
Before me, the undersigned authority, on this day personally appeared
known to me to be the person
whose name is subscribed to the above instrument, who being by me duly sworn on oath states that he/she is duly authorized to make the above report and that
he/she has knowledge of the facts stated therein, and that said report is true and correct.
_______
______________________
_________
Subscribed and sworn to before me this
day of
, 20
_____________________________________
SEAL
____________________
Notary Public in and for
____________________
My commission expires
_______________________________
County,

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