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OWNER'S TANK ID OTHER ID INITIAL SERVICE DATE Manufacturer: Contents: Construction Date: Last Repair/Reconstruction Date: Dimensions: Ca acit : Last Change of Product Date: Design: ❑ UL ❑SWRI ❑API ❑Other El Unknown ❑ Horizontal ❑Vertical ❑Rectangular Construction: ❑ Bare Steel ❑Cathodically Protected{Check one:A.❑Galvanic or B.❑Impressed Current)Date Installed: ❑Coated Steel ❑Concrete encased steel ❑Stainless steel ❑Other ❑ Double-Bottom ❑Double-Wall ❑Lined inside;Date lining installed: Spill control: ❑Earthen Dike ❑Steel Dike ❑Concrete CRDM: F-1 yes ❑no ❑None ❑Other If yes,type:❑ Release Prevention Barrier❑Elevated tank ❑Double bottom tank Tank elevated on supports ❑yes ❑no ❑ Double wall tank ❑CE-AST ❑other Support material: ❑steel ❑concrete ❑ other Release Prevention Barrier: ❑yes ❑no If yes,Date Installed: AST Category: ❑Category 1 ❑ Category 2 ❑ Category 3 If yes,Type:❑concrete❑synthetic liner ❑clay liner ❑ steel ❑other OWNER'S TANK ID OTHER ID INITIAL SERVICE DATE Manufacturer: Contents: Construction Date: Last Repair/Reconstruction Date: Dimensions: Ca acit : Last Change of Product Date: Design: ❑UL ❑SwRI ❑API ❑Other ❑Unknown ❑ Horizontal ❑Vertical ❑Rectan alar Construction: ❑ Bare Steel ❑Cathodically Protected(Check one:A.❑Galvanic or B.❑Impressed Current)Date Installed: ❑Coated Steel ❑Concrete encased steel ❑Stainless steel ❑Other ❑Double-Bottom ❑Double-Wall ❑Lined inside;Date lining installed: Spill control: ❑ Earthen Dike ❑Steel Dike ❑Concrete CRDM:❑yes ❑no ❑None ❑Other If yes,type:❑ Release Prevention Barrier❑Elevated tank ❑Double bottom tank Tank elevated on supports ❑yes ❑no ❑ Double wall tank ❑CE-AST ❑other Support material: ❑steel ❑concrete ❑ other Release Prevention Barrier: ❑yes ❑no If yes,Date Installed: AST Category: ❑Category'I ❑ Category 2 ❑ Category 3 If yes,Type:❑concrete❑synthetic liner ❑clay liner ❑ steel ❑other AST Record Page 2 of 2