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OWNER'S TANK ID A ay4s'Q 4t a-'E"vn OTHER ID -71,t 7 INITIAL SERVICE DATE <br /> Manufacturer: Vx)C — 5Lxi 14 Contents: T4 A Construction Date: C70 Last Repair/Reconstruction Date: <br /> Dimensions: ` ' d jQ Capacity: 20 000 <br /> %cri< Last Change of Product Date: <br /> Design: ❑ UL ❑SwRI ❑API ❑Other ❑ Unknown <br /> 5kHorizontal ❑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 2f Concrete CRDM;n yes ❑no <br /> ❑ None ❑ Other If yes,type: ❑ Release Prevention Barrier Elevated tank ❑ Double bottom tank <br /> Tank elevated on supports 19 yes ❑ no ❑ Double wall tank ❑CE-AST ❑other <br /> Support material: T"-steel ❑concrete ❑ other <br /> Release Prevention Barrier:dyes ❑ no If yes, Date Installed: AST Category: Category 1 ❑ Category 2 ❑ Category 3 <br /> If yes,Type:7J Soncrete❑synthetic liner ❑clay liner ❑ steel ❑other <br /> OWNER'S TANK ID I OTHER ID INITIAL SERVICE DATE <br /> Manufacturer: Contents: Construction Date: Last Re air/Reconstmction Date: <br /> Dimensions: Capacity: 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 ❑Concrete CRDM: ❑yes ❑no <br /> ❑None ❑Other If yes,type: ❑ Release Prevention Barrier❑Elevated tank ❑ Double bottom tank <br /> Tank elevated on supports ❑yes ❑ no ❑ Double wall tank ❑CE-AST ❑other <br /> Support material: ❑steel ❑concrete ❑ other <br /> Release Prevention Barrier: ❑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 2 of 2 <br />