All fields marked with a (!) are required. You will not be able to submit the form without completing them.

Submitter Information
	(!)Facility Number (see invoice)
	(!)Person Reporting Release
	(!) Anti-Spam Code: Write the characters in the image:
	(!)Company
	(!)Area Code & Telephone Number
	(!)email Address
I. OWNERSHIP OF TANKS
	Please check if new owner's address.
	(!)Name
	(!)Company
	(!)Street Address
	Street (cont.)
	(!)City
	(!)State
	(!)Zip
	(!)County	Select a county Alcona Alger Allegan Alpena Antrim Arenac Baraga Barry Bay Benzie Berrien Branch Calhoun Cass Charlevoix Cheboygan Chippewa Clare Clinton Crawford Delta Dickinson Eaton Emmet Genesee Gladwin Gogebic Grand Traverse Gratiot Hillsdale Houghton Huron Ingham Ionia Iosco Iron Isabella Jackson Kalamazoo Kalkaska Kent Keweenaw Lake Lapeer Leelanau Lenawee Livingston Luce Mackinac Macomb Manistee Marquette Mason Mecosta Menominee Midland Missaukee Monroe Montcalm Montmorency Muskegon Newaygo Oakland Oceana Ogemaw Ontonagon Osceola Oscoda Otsego Ottawa Presque Isle Roscommon Saginaw Sanilac Schoolcraft Shiawassee St Clair St Joseph Tuscola Van Buren Washtenaw Wayne--Detroit Wayne--Hamtramck Wayne--Highland Park Wayne--Other Wexford
	(!)Area Code & Telephone Number
II. LOCATION OF TANKS
	Please check if same as Section I. (If checked, fields in this section marked with a (*) are optional.)
	(!)(*)Contact Person for Location
	(!)Facility Name (or Company Site Identifier)
	(!)(*)Street Address (P.O. Box not acceptable)
	Street Address (cont.)
	(!)(*)City
	(!)(*)State
	(!)(*)ZIP
	(!)(*)County	Select a county Alcona Alger Allegan Alpena Antrim Arenac Baraga Barry Bay Benzie Berrien Branch Calhoun Cass Charlevoix Cheboygan Chippewa Clare Clinton Crawford Delta Dickinson Eaton Emmet Genesee Gladwin Gogebic Grand Traverse Gratiot Hillsdale Houghton Huron Ingham Ionia Iosco Iron Isabella Jackson Kalamazoo Kalkaska Kent Keweenaw Lake Lapeer Leelanau Lenawee Livingston Luce Mackinac Macomb Manistee Marquette Mason Mecosta Menominee Midland Missaukee Monroe Montcalm Montmorency Muskegon Newaygo Oakland Oceana Ogemaw Ontonagon Osceola Oscoda Otsego Ottawa Presque Isle Roscommon Saginaw Sanilac Schoolcraft Shiawassee St Clair St Joseph Tuscola Van Buren Washtenaw Wayne--Detroit Wayne--Hamtramck Wayne--Highland Park Wayne--Other Wexford
	(!)(*)Area Code & Telephone Number
RELEASE INFORMATION
	(!)Release Report:	Suspected Confirmed
	(!)Date Release Discovered:
	(!)Time Release Discovered:
TANK INFORMATION
	(!)Tank Number   (!)Size of Tank   (!)Substance Released   (!)Construction of Tank   (!)Reason for believing release occurred (as indicated on UST Invoice) (gallons) (e.g. presence of product, failed tightness test, vapors, stains) (Please submit multiple request if you have more tanks.)
Comments

INSTRUCTIONS

Suspected release reports are required to be canceled or upgraded within 14 working days. The underground storage tank (UST) owner/operator is responsible for the release investigation.

Confirmed release reports received are immediately forwarded to the appropriate district/field office of the WHMD.

The owner/operator must follow rules for site characterization and cleanup as given in Part 213, Leaking Underground Storage Tanks (LUST), of the Natural Resources and Environmental Protection Act, 1994 PA 451, as amended (Act 451).

Section 280.72 of the Michigan UST rules states that a site assessment is not required if a confirmed release has been reported for the UST system (tank and piping).

If the UST is not properly registered, the owner/operator MUST submit a completed registration form with the $100 per tank fee prior to UST removal.

Per Section 21102 of Part 211, Underground Storage Tank Regulations, of Act 451, after the UST system(s) has/have been removed from the ground, the owner/operator MUST submit an amended registration form to avoid future billing for closed tanks.

UST CLOSURE/REMOVAL BASED ON A CONFIRMED RELEASE: