Leak Notification Form

Leak Notification Form

Underground Petroleum Storage Systems (UPSS)
Notification of a pollution incident to the relevant authority under Part 5.7 of the Protection of the Environment Operations Act 1997 (POEO Act)

On 1 September 2019, local Councils reassumed responsibility for regulating privately owned UPSS.

The person responsible for the UPSS must, immediately after becoming aware of a pollution incident, notify the relevant authority. Where the notification was verbal, a written notification using this form must be submitted within seven days. The person responsible is the person who has management and control of the UPSS.
This form should be completed where at least one of the following scenarios apply to the UPSS site (select appropriate):

A leak from a UPSS, verified in accordance with loss detection or incident management procedures, that is causing or threatens material harm to human health or the environment.There is evidence on the site of free-phase hydrocarbons in surface water and/or groundwater.There is evidence that offsite migration of hydrocarbons could occur, is occurring, or has occurred.

Section C: Person responsible for the UPSS site
If the 'person' responsible is a Corporation, an individual who is authorised to act on the Organisation's behalf must be nominated.
Company Name (if applicable)
Contact person (if person responsible is not a natural person)

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Postcode