Texas Petroleum Storage Tank Program - Incident Report (Ir) Form
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1FORM INSTRUCTIONS: Use this form to report suspected/confirmed PST releases to the Texas Commission on Environmental Quality
(TCEQ) PST - Responsible Party Remediation Section - 512/239-2200 (phone), 512/239-2216 (fax),
pstrpr@tceq.state.tx.us
(e-mail). All
suspected/confirmed releases must be reported w/in 24 hours of discovery. For emergencies only, call 512/239-2120 or after regular
business hours, page 512/606-9197.
TEXAS PETROLEUM STORAGE TANK PROGRAM - INCIDENT REPORT (IR) FORM
Facility Name: ___________________________________________________________________________
Facility Information
Address: _______________________________________________________________________________
City: ____________________________________________ County: _______________________________
Facility ID: __________________ G ‘ghost’ tank
Pre-existing LPST ID: _______________ GN/A GUnk
Contact Person: _____________________________________ Phone: _____________________________
Resp onsib le Party
(RP) Information
Company: ___________________________________________ Fax: _____________________________
Address: _______________________________________________________________________________
City: ____________________________________________ State/Zip: ______________________________
Contact Person: _____________________________________ Phone: _____________________________
Releas e reported by:
(if different from above)
Company: _____________________________________________________________________________
Address: _______________________________________________________________________________
City: ____________________________________________ State/Zip: ______________________________
G tank owner
G tank operator
G land owner
G other (specify):
The RP is the:
Release is: G Confirmed
G Suspected
Date of discovery: _________________________
Release Information
Check all that apply:
Discovery
Substance
Cause
G Routine tank closure or
G Gasoline (Leaded/Non-leaded/Unknown)
G Spill
G Diesel/Fuel oil
G Overfill
site assessment
G Laboratory analytical results
G Waste oil
G Human error
G Free product or sheen
G Hydraulic/transmission/mineral oil
G Faulty installation
G Odors
G Jet fuel/kerosene
G Corrosion
G Automatic tank gauge
G Petroleum - unknown type
G Unknown
G Probe or sensor
G Hazardous substance: _____________
G Other (describe):
G Inventory records
G Unknown
G 1-mo. SIR failure or ‘inconclusive’
G Other (describe): _________________
Location
G 2-mo. inventory control discrepancy
G Tankhold
G Tank tightness test failure
G Dispenser area
Impact
G Line tightness test failure
G Groundwater
G Pipe chase
G Groundwater monitoring well
G Surface water
G Remote fill port
G Vapor detector (auto or manual)
G Soil
G Other (describe):
G Water supply contamination
G Air
G pressurized piping
G suction piping
G unknown
G N/A
Tank system has/had:
Other parties notified (Fire, police, etc. - list):
G Yes
G No
Free product present?
Describe steps taken to control and abate release (system repairs, free product removal,
etc.), and/or actions taken to mitigate any fire, explosion, or vapor hazard:
Additional comments (add pages as needed):
<<< TCEQ USE ONLY >>>
PM - complete this form when a report of a suspected/confirmed release from a regulated storage tank is received & provide
G phone
G fax
G e-mail (print out & attach)
G other (explain on additional pages or on back).
to Admin staff. Information received by
Date release was reported to TCEQ: _______________________. Initial here if new LPST ID No. should be assigned: _______PM
_______TL.
New LPST ID# ______________________ Admin - fax completed form to RP & enter into appropriate databases. Info entered in G RDR Db G SMAPS
on ____________________(date) by _______(initials). Faxed to RP on ____________________(date).
TCEQ-20097 (December 2003)
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