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STI SP001 AST Record <br /> Form completed by(Name) Date <br /> (Title) <br /> OWNER INFORMATION FACILITY INFORMATION INSTALLER INFORMATION <br /> Name Name <br /> Name <br /> Number and Street Number and Street Number and Street <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 OTHER ID INITIAL SERVICE DATE <br /> Manufacturer Contents: Construction Date: Last Repair/Reconstruction Date: <br /> Dimensions: Capacity: Last Chan a of Product Date: <br /> Design: ❑ UL ❑SWRI ❑API— El Other ❑Unknown <br /> ElHorizontal ElVertical <br /> [IRectangular <br /> Construction: ❑Bare Steel ❑Cathodical]y 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 1 of 2 <br />