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<br />Florida Department of Environmental Regulation
<br />Twin Towers Ot11cc: BidS, . 2600 Bl:.1.ir Scone ROlld . 'P.LlI:thas.see, Floriw ,\~,~"N,.!..()()
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<br />DlII F...",. 17. '/11.80Clllll
<br />'''''' r ,.." S.". TMll f\eQoIIr.aon Form
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<br />I DEll """""'000 No
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<br />IF"1d '0 br DfIll
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<br />Storage Tank Registration Form
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<br />1, DER Facility ID Number:
<br />3, New Registration 0
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<br />Pie... Print. or 1'fpe . Review Instructions Before Completing Form
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<br />!5IR03CO?J5
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<br />2, Facility Type:
<br />Tank(s) Revision G:J'
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<br />: 5, Facility Name:
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<br />New Owner Data 0 Facility Revision 0
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<br />Tank(s) Address: 'lo~ As..J't:?" A
<br />Cily/State/Zip: "L.e f h \/ r h;l \ ~ T L-
<br />Contact Person: J" Y\ ,,\~(\ l"Y\ en-\-cl, ~ f\ ; a r\. (l e
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<br />6, Financial Responsibility Type: St' \ {' - \ l'\ 8, \ ^ r-e C
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<br />4, County and Code of tank(s) location:
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<br />Telephone: ( 5/3) .::J.d...~ - i-f 74 ()
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<br />7a, Tank(s) Owner:
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<br />GTE
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<br />Owner Mailing Address: -p, 0, b 0 'I.. ll0 M C- 7 / !
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<br />City/State/Zip:
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<br />Contact Person:
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<br />Telephone: (~) ~:i=-~ rz.~l_,,_
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<br />i 7b. New Owner Signature/Change Date:
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<br />8, Location (optional) Latitude: _0_' _" Longitude: _0_'_"
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<br />Section_ Township_ Range_
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<br />Complete On. Line For Each '1lInk At This Facility (Use Codes. See Instructions)
<br />Complete 9 . 16 for tanlt$ In use; 9 . 19 for tanks out of use
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<br /> 9 10 11 12 13 14 15 16 17 18 19 1
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<br />20,
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<br />DPR# ,_
<br />Department of Professional Regulation License Number'
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<br />Certified Contractor.
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<br />.For nfIW tank installation (X tank remC1.'8l
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<br />To the be8t at my knowledge and belief all information submitted on this form is true. accurate and complete.
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<br />Print name & title of owner or authorized person Signature Date
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