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STI SP001 AST Record <br /> Form completed by(Name) Ge4q Cot,Ir, AI Date <br /> (Title) L,nf sea^yi c€, fArwhid ' <br /> OWNER INFORMATION FACILITY INFORMATION INSTALLER INFORMATION <br /> Name <br /> F/ Name Name <br /> A+/All c Av;4;o>t A41anfrc. AV," Pvn <br /> Number and Street Number and Street Number and Street <br /> 6'36ti S C%' Ler 4i ' 64 6365 `' , Sf <br /> City, State,Zip Code City,State,Zip Code City,State,Zip Code <br /> Regulatory facility ID number(if applicable) <br /> OWNER'S TANK ID tlR C ac e n OTHER ID V F' nK INITIAL SERVICE DATE <br /> v <br /> Manufacturer: .F C4cr ^"5 -5. Contents: Ad ,,S Construction Date: 0'V//EtG2 Last Repair/Reconstruction Date: <br /> Dimensions, (.0 -49 �t ri•tP' + Capacity: 12,,60o5,jjcjL Last Change of Product Date: <br /> Design: ❑UL ❑SwRi ❑API ❑Other ❑Unknown <br /> Horizontal ❑Vertical ❑Rectangular <br /> Construction: ❑ Bare Steel ❑Cathodically Protected(Check one:A❑Galvanic or B.❑Impressed Current)Date Installed: <br /> Coated Steel ❑Concrete encased steel ❑Stainless steel ❑Other <br /> ❑Double-Bottom ❑Double-Wall ❑Lined inside;Date lining installed: <br /> Spill control: ❑Earthen Dike ❑Steel Dike 5ff Concrete CRDM:Xyes []no <br /> ❑ None ❑Other If yes,type:❑ Release Prevention Barrier Elevated tank ❑ Double bottom tank <br /> Tank elevated on supports gryes ❑no ❑ Double wall tank ❑CE-AST ❑other <br /> Support material: �W'steel ❑concrete ❑ other <br /> Release Prevention Barrier:0 yes ❑ no If yes, Date Installed: AST Category: Category 1 ❑ Category 2 ❑ Category 3 <br /> If yes,Type: concrete❑synthetic liner ❑clay liner ❑ steel ❑other <br /> AST Record Page 1 of 2 <br /> n <br />