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Form completed by (Name) <br />(Title) <br />OWNER INFORMATION FACILITY INFORMATION INSTALLER INFORMATION <br />Name Name Name <br />Number and Street <br />City. State. Zip Code <br />INITIAL SERVICE DATE <br />Last Repair/Reconstruction Date: <br />Design: Other <br />Construction: <br /> Double bottom tank <br />48 | Pa ::- <br />Construction Date:_________ <br />. Last Change of Product Date: <br /> Bare Steel <br />Coated Steel <br /> Double-Bottom <br />feQ Unknown API <br /> Rectangular <br /> Cathodically Protected (Check one: A. Galvanic or B. Impressed Current) Date Installed: <br /> Concrete encased steel Stainless steel Other <br /> Double-Wall Lined inside: Date lining Installed: <br />Number and Street <br />%. Huu Oft <br />City, State, Zip Code J <br />CRDM: [$yes Ono <br />If yes. type: Release Prevention Barrier Elevated tank <br /> Double wall tank CE-AST other <br />Number and Street <br />wee op <br />City, State, Zip Code <br />:,o:C£> oi urer <br />Regulatory facility ID number (if applicable) <br />AST Category: ^Category 1 Category 2 Category 3 <br />OTHER ID <br />Manufacturer: Contents: YsvesF a <br />Dimensions:'2-~? L Capacity: \CXCfO Oft <br /> UL SwRI <br /> Horizontal_____________________ Vertical________________ <br />OWNER'S TANK ID 16V. Tank <br />Spill control: Earthen Dike Seel Dike Concrete <br />____________ None Other _ __________ <br />Tank elevated on supports i^l yes no <br />Support material: ^steel □ concrete □ other <br />Release Prevention Barrier: ^.yes no If yes, Date Installed: <br />If yes. Type: ^concrete synthetic liner Delay liner steel □other <br />STI SP001 AST RecordiloVKP. (M___________ <br />Soo wnrrnpr Date