Laserfiche WebLink
n91E(rCr{te DEP Form 8 62-761.900(21 <br /> rks Flo/ida Department of En vironmen tal Pi otection Form Title Storage Tank Registration Form <br /> ..? Twin Towers Office Bldg.•2600 Blair Stone Road•'Tallahassee,Florida 32399.2400 <br /> Effective Date July 13.1998 <br /> DEP Application No. <br /> Storage Tank Facility Registration Form (Filled in by DEP) <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 completing the form. <br /> Check all that apply New Facility Registration 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 DEP Facility ID Number <br /> Facility Name <br /> Address,City,Zip <br /> Facility Contact Contact Telephone <br /> Facility Type Description Financial Responsibility <br /> 24 Hr Emergency Contact 24 Hr Emergency Phone <br /> RESPONSIBLE PARTY INFORMATION-Identify individual or business responsible for storage tank registration&registration renewal. <br /> Name <br /> [ 4 ] 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 Tank Owner Tank Operator 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 NU Capacity Installed Content Status/Effective Date Construction Piping Monitoring <br /> Certified Contractor—performing tank installhemoval DBPR License No <br /> Registration Certification-To the best of my knowledge and belief,all information submitted on this form is true,accurate,and complete. <br /> Printed Name&Title Signature Date <br /> Central District Southeast District South District <br /> FL DEP DISTRICT OFFICES 3319 Maguire Blvd,Suite 232 400 Congress Ave. 2295 Victoria Ave,Suite 364 <br /> Orlando,FL 32803 W Palm Beach,FL 33416 Fort Myers,FL 33901 <br /> 407-894-7555 561-681-6600 941-332-6975 <br /> Northwest District <br /> 160 Governmental Center Blvd. Northeast District Southwest District Marathon Branch <br /> Pensacola,FL 32501 7825 Baymeadows Way,Suite 200 13051 N.Telecom Pkwy 2796 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 305-289-2310 <br />