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OWNER'S TANK ID OTHER ID INITIAL SERVICE DATE Manufacturer: Contents: Construction Date: Last Repair/Reconstruction Date: Dimensions: Capacity: Last Change of Product Date: Design: ❑ UL ❑ SWRI ❑API ❑ Other ❑ 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: ❑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: Capacity: Last Change of Product Date: Design: ❑ UL ❑ SwRI ❑API ❑ Other ❑ 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: ❑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 AST Record Page 2 of 2