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AST Record Page 1 of 2 STI SP001 AST Record Form completed by (Name) ___________________________________________________________ Date ______________ (Title) ____________________________________________________________ OWNER INFORMATION FACILITY INFORMATION INSTALLER INFORMATION Name Name Name Number and Street Number and Street Number and Street City, State, Zip Code City, State, Zip Code City, State, Zip Code Regulatory facility ID number (if applicable) . 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 None Other _______________________ CRDM: yes no If yes, type: Release Prevention Barrier Elevated tank Double bottom tank Double wall tank CE-AST other ______________ Tank elevated on supports yes no Support material: steel concrete other _________________________ Release Prevention Barrier: yes no If yes, Date Installed: ________________ If yes, Type: concrete synthetic liner clay liner steel other _________ AST Category: Category 1 Category 2 Category 3