Form Ogb - 21 - Authorization To Clean Tank

STATE OIL AND GAS BOARD OF ALABAMA

Form OGB - 21

420 Hackberry Lane

5 / 00

P.O. Box 869999

Tuscaloosa, Alabama 35486-6999

(205) 349-2852

Fax (205)349-2861

Authorization to Clean Tank

(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

in.

Tank capacity

bbis Tank height

ft.

ft.

in. Sales Outlet height

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 completed

Date cleaning began

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

Permission to clean tank approved by

Date

(Oil & Gas Board Agent)

Date of last cleaning

Phone number

Person to contact

regarding this

Fax number

form

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 or treating of said contents in said tank. 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, transportation of said contents,

Remarks

, 20

Executed this the

day of

Signature

known to me to be the person

Before me, the undersigned authority, on this day personally appeared

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.

day of

, 20

Subscribed and sworn to before me this

SEAL

Notary Public in and for

County,

My commission expires