Attachment A - STI-SP001-AST-Record-7th-Ed.pdf

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

February 2024, 7th Edition

AST Record Page 2 of 2

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

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

February 2024, 7th Edition