Storage Tank System Leak Autopsy Report Form
Please check all blocks that apply for the entire form
Site Information
Facility Name
Facility ID Number
County
Owner/Operator Name
System Information (At the Time of Release)
Tank
Tank Type
 Underground Storage Tank
 Shop-fabricated Aboveground Storage Tank
 Field-erected Aboveground Storage Tank
Tank Installation Date:____________________________________
Tank Manufacturer Name:_________________________________
Piping Installation Date___________________________________
Piping Manufacturer Name:________________________________
(Note if Unknown)
(Note if Unknown)
(Note if Unknown)
(Note if Unknown)
System Information
Please check all blocks that apply for the entire form
USTs
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Material
Galvanized Steel
Fiberglass
Composite
Unprotected Steel
Other Approved
Concrete
Polyethylene
Unknown
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Other Attributes
Sacrificial Anodes
Impressed Current System
Internal Lining
Single Wall
Double Wall (same material)
Double Wall (different material)
Secondary Containment with a liner
Other Approved (Tank Bladders, etc.)
Compartmented
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Ancillary Equipment
Spill Containment Bucket
No Spill Containment
Unknown
Overfill Protection
Ball Check Valve
Flow Shut-Off
Tight Fill
Alarm System
No Overfill Protection
Unknown
ASTs
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Material
Steel
Concrete
Polyethylene
Approved Synthetic
Other Approved
Cut and Cover
Unknown
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Other Attributes
Shop-Fabricated
Field-Erected
Synthetic liner beneath tank (SC)
Concrete beneath tank (SC)
Double Wall
Internal Secondary Containment
Other Approved Secondary
Containment
Single Wall
Impressed Current System
Synthetic Dike Field Liner
Concrete Dike Field Liner
Other Approved Dike Field Liner
Secondary Containment around
pumps/valves
No Dike Field Secondary
Containment
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Ancillary Equipment
Overfill Protection
Flow Shut-Off
Alarm System
Gauges
Other Approved
No Overfill Protection
Spill Cont. (for ShopFabricated Tanks)
No Spill Containment
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Piping – AST or UST
Material
Other Attributes
Ancillary Equipment
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Galvanized Steel
External Coating
Fiberglass
Composite
Unprotected Steel
Flexible Synthetic
Other Approved
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Dispenser Sump(s)
No Dispenser Sumps
Unknown
Piping Sump(s)
No Piping Sumps
Unknown
Single check valve
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Sacrificial Anodes
Impressed Current System
Single Wall
Double Wall (same material)
Double Wall (different material)
Secondary Containment with a liner
Other Approved Secondary
Containment
Box-trench Liner
Pressurized
Not-Pressurized except when in use
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Unknown
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Suction
Manifolded
Bulk Product
Small Diameter
Hydrant System
Aboveground, no contact with soil
Over Surface Water
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Foot Valves
Unknown
Mechanical Line Leak
Detector (LLD)
Electronic LLD
Unknown
No Line Leak Detector
Leak Detection
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UST
Internal Interstitial
Monitoring
Interstitial Monitoring
within a liner system
Groundwater Monitoring
Wells
Vapor Monitoring Wells
SIR
ATG
Tank Tightness Testing
Inventory Reconciliation
Manual Tank Gauging
Visual Inspections
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Other Approved Methods
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AST
Interstitial Monitoring
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Groundwater Monitoring Wells
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Vapor Monitoring Wells
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Vapor Monitoring Probes
Tracer Technology
Visual Inspections
Cable Systems
Fiber-optic Technologies
SPCC Plans
Tank Shell Monitoring System
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Other Approved Methods
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Piping
Interstitial Monitoring
Groundwater Monitoring
Wells
Vapor Monitoring Wells
Vapor Monitoring Probes
Tracer Technology
Visual Inspections
Cable Systems
Pressure Tests (Bulk)
Pressure Tests (Small)
Mechanical Line Leak
Detectors
Automatic Line Leak
Detectors
Other Approved Methods
Release Information
Date of receipt of test results or discovery of confirmed discharge: __________________________month/day/year
Estimated number of gallons discharged:_______________
Latitude and Longitude_____________________
Discharge affected
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Air
Soil
Ground water
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Drinking water well(s)
Surface water
Other________________________________
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Used/waste oil
New/lube oil
Mineral acid
Petroleum Contact Water
Pesticides
Chlorine Compounds
Ammonia Compounds
Petroleum Derivative Products
Other
Unknown
Type of regulated substance discharged: (check one)
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Gasoline
Diesel
Kerosene
Jet fuel
Aviation gas
Gasohol
Emergency Generator Diesel Fuel
Heating oil
Hazardous substance
Grades 5 & 6 Residual Oils
Method of Discovery of the Discharge
 Leak Detection Methods
***If Leak Detection, specify method:
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Closure-in-Place
Removal
Installation or Upgrade
Property Transfer
Visual
Olfactory
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Water in Tank
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Tank or LineTightness
Testing Performed for other
Reasons_______________
Internal Inspection
Unknown
Other ____________________
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Inventory Reconciliation
Manual Tank Gauging
Groundwater Monitoring
Vapor Monitoring
Secondary/Interstitial
Monitoring
Annual or Regularly
Scheduled Tank
Tightness Testing
Annual or Regularly
Scheduled Line
Tightness Testing
SIR
ATG
Analytical tests or samples
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Mechanical LLD
Electronic LLD
Visual Inspection of ASTs
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Bulk Product Piping
Pressure Tests
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Fiber-Optic or Cable
Technologies
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Other Approved Methods
Vapor Monitoring Probes
Other_______________
Visual Inspection of USTs
Tracer technologies
Did the method of Leak Detection relied on for compliance purposes fail to detect the release? (Y,N, U)
If so, what was the method relied on for compliance purposes?___________________________________
Source of Discharge:
 UST
 Small Diameter Piping
 Flex-Connector
 UST Vent Line
 UST Fill Pipe
 UST Turbine Pump
 Dispenser
 Delivery Vehicle
 UST Electronic/Mechanical Line Leak Detector
Other _______________
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Cause of the Discharge
 Loose Component (filter, piping connection, bung, etc)
 Corrosion
 Spill
 Puncture
 Overfill
 Material Failure (crack, split, etc.)
 Weather
 Material Incompatability
 Unknown
 Other _____________________________
Shop-Fabricated AST
Field-erected AST
Bulk Product Piping
Pipeline
Valves (ASTs)
Pump (ASTs)
Barge or Vessel
Bulk Product Dock Piping (connected to ASTs)
Hydrant Pit (AST systems)
AST Vents
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Improper Installation
Vehicle Accident
Physical or Mechanical Damage
Human Error
Vandalism or Malicious Intent
Fire/Explosion
Release Identified by:
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Owner/Operator
Third Party
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Service Contractor
State Inspector
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Local Government Inspector
Other
Additional Information: (Attach Photos if available)
SIGNATURE:_________________________________________
AFFLILIATION:_______________________________________