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: 0,11AEtt`°_ DEP Fomi# 62-761.900(2] <br /> a' Florida Department of Environmental Protection <br /> Font Titic S{Or3Ae Teak$ggistration Farm <br /> \ Twin Towers Office Bldg.0 2600 Blair Stone Road 0 Tallahassee,Florida 32399.2400 <br /> FLOR>:,., <br /> T Effective Date luly 13,199$ <br /> `-`::mss'-`"`_`' • • DEPApplica[ionNo. <br /> Storage Tank Facility Registration Form (FtlledinbyDEF) <br /> Submit a completed form for the facility when registration of storage tanks or compression vessels is required by Chapter 376.303,Florida Statutes <br /> Please review Registration instructions before corn•letin• the form. <br /> Check all that apply New Fad' Re•istration New Owner New Tanks <br /> Information for existing Information for existing owner Information for existing tank(s) <br /> facility changed or updated _ changed or updated changed or updated <br /> FACILITY INFORMATION County Miami Dade County DEP Facility ID Number 1 9807384 <br /> Facility Name Sunny Isle Beach City—Government Center <br /> Address,City,Zip 18070 Collins Ave. <br /> Facility Contact Bill Evans Contact Telephone 786-586-7533 <br /> Facility Type Description H — <br /> Financial Responsibility <br /> 24 Hr Emergency Contact Bill Evans 24 Hr Emergency Phone 786.586.7633 <br /> RESPONSIBLE PARTY INFORMATION-Identify individual or business responsible for st_ora a tank registration&registration renewal. <br /> Name [ 11 I Facility Account Owner-pays registration fees <br /> Mail Address STCM Account Number <br /> City,State,Zip Effective Date of Ownership <br /> Contact Provide Email Address for Contact In space below <br /> Telephone <br /> Check all roles that apply Facility Owner [ f Tank Owner Tank Operator I Property Owner <br /> ADDITIONAL RESPONSIBLE PARTY INFORMATION--Identify additional individual or business responsible for storage tank management,fueling <br /> operations,and/or cleanup activities at the facility location above. Provide additional information In an attachment if necessary. <br /> Name Other relationship type(s) Effective Date <br /> Mail Address Facility Owner <br /> City,State,Zip Tank Owner <br /> Contact Tank Operator <br /> Telephone Property Owner <br /> TANKNESSEL INFORMATION-Complete one row for each storage tank or compression vessel system located at this facility. <br /> Tank ID ` TN A/U [ Capacity Installed Content - Status/Effective Date Construction Piping Monitoring <br /> r <br /> N-925538 A 2000 , 2-1-2005 G , U 02/01/2005 CFNPRX J M 23FKNQ <br /> Certified Contractor-performing tank install/removal DBPR License No <br /> • <br /> Registration Certification-To the best of my knowledge and belief,all Information submitted on this form is true,accurate,and complete. <br /> Printed Maine&Title Bill Evans Public Works Director Signatu c____.__ 03/05/2009 <br /> Central District Southeast District South District <br /> FL DEP DISTRICT OFFICES 3319 Maguire Blvd,Suite 232 400 Congress Ave. 2295 Victoria Ave,Suite 384 <br /> Orlando,FL 32803 W Palm Beach,FL 33416 Fort Myers,FL 33901 <br /> Northwest District 407-894.7555 581-881.8800 941-332-6975 <br /> 160 Governmental Center Blvd. Northeast District Southwest District Marathon Branch <br /> Pensacola,FL 32501 7825 Baymeadows Way,Suite 200 13051 N.Telecom Pkwy 2798 Overseas Hwy,Suite.221 <br /> 850-595-8360 Jacksonville,FL 32256 Temple Terrace,FL 33619 Marathon,FL 33050 <br /> 904-448-4300 813.744.6100 <br /> 305-289-2310 <br />