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<br />DEC-28-2005 09:20 From:
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<br />To:813 780 0021
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<br />P.2/2
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<br />Flor;da Department of EIlv;rOlrmelltal Protection
<br />I WIfl I owers ()Ilie,~ Flltlp . '1100 L11:lIr SlOn~ Road - T31l3h~~5CC. Fllllida 323'1'1-.!400
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<br />1)1.,I'''nrnJolj_''~_....
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<br />"'"1m, I,l ,. Slj.\.r~~.k.Jl~tJlra'ian I"flrm
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<br />l:lIh"lIVC (linc: July 1.1. ICl~,&
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<br />Storage Tank Facility Registration Form
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<br />III I' Arpll~"tICJn No
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<br />'hU<ll II,I.y I)~r I
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<br />Submil a c;ornpletec:l form for the faci~ty when registretiOIl of storage lanks or compfll66ion vP',,~~ls is required by Chuplcr 376.303, Florida Statutes
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<br />Please revi_ Registration Instructions before completing the form.
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<br />PleBse check 811 that a
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<br />New Re istration
<br />Fac~ity Info Updat$'Correction
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<br />A, FACILITY tNFORMATION
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<br />County: Pasco
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<br />EP Facility 10:
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<br />datlllCorTection. ,
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<br />J
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<br />151) 9806767
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<br />Faclhly Neme
<br />Facility Address
<br />t-ACllrty Contact:
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<br />Rinker Malerials - Zsohvrf1ills
<br />3!l4ti GUlmlflflct Boulev,8rt1
<br />Isaac Morffv - Ooerations For&man
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<br />City:
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<br />ZeDlwrhllls
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<br />FaCility Type(s). .._C
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<br />b~Em...~'YCo_'
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<br />NAICS Code:
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<br />32/:.12U
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<br />Zip 33542
<br />Business Phone: ~~600
<br />Financial Responsibilily. C
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<br />Jeffrev R, Porter
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<br />Emergency Phone: ~_L..llQ:5850
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<br />-:J
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<br />B. RESPONSIBLE PERSON INFORMATION - Identify Individual(s) I)' BU1ilness(es) responsible for slorage tank management, rllchng operations andlor
<br />cleanup Cll:hvities at the facility location named above, Provide additional information In an attachment if neeeuary.
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<br />Name. Rinker Materials of Florida, Inc
<br />Mall address: 1501 Belvedere Road
<br />City, ST, Zip: West Palm BeDell. I-L 3340El
<br />Contact: Jeffrey R. Poner - Perfll,t , Project Manager
<br />Telephone (561) 820-8"15
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<br />~acilily - Responsible Person Relatron Type, Errcclivl! Dale
<br />[oJ] Facility Account Owner (pays fees)
<br />1-11l1llily Account Owner information must be provrded wht," Ihe
<br />facility contains aClivo (in-use) storage tanks on ,;l1e
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<br />STeM Aecount Number (If known)
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<br />18304
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<br />Identify other eppropriate faclllty relationships for this party, [;I J Facility OwnerlOperator [II J PrOperly ()wnar N] Storage Tan~ Owner
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<br />Name'
<br />Mail address.
<br />City, ST, Zip
<br />Contact.
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<br />Other owner, relationsh
<br />[ ] Facility OwnerlOpe
<br />[ ] Proporty Owner
<br />[ ] Sloragll Tank Ow
<br />[ ] Othor
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<br />ip type(s) Ftlective Date
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<br />rIItor
<br />ner
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<br />Telephone:
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<br />C. TANKlVESSEL INFORMATION. Complete one row for eilch lItorage tank or compression vessel system located at this faC;i1ity,
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<br />TanklD TIV A1U Capacity Installed Content Status/Eftectlve Oate Construction Piping Monitoring
<br />1 T A 15.000 08 , 04 D B 01 I 05 A,e.l. K.~ A. B.I F Q
<br />2 T A 20.000 12'05 D U 12/05 C, I, K A,8.1 F,O
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<br />Certified Conlractor (performing tank installation or rElIllu\l~I)' _ Fred Rico & Associates Inc,
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<br />DSPR Liccn:;c No ' PC C050G33
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<br />Registration Certlflcatlon: To the beSl of my IInowledg!! and belief, all information submitted on this form is true, accurate. and complete.
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<br />_J~rev R. Porter - Permit (Proiect Manaaer . c:::=:::::-~~ ~~ ~/'Z 8/ ~..5
<br />Prinled Name & Tltl!! SIgnature -- Date
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<br />DEP a2.'61 900(')
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<br />Nnrtl"l~' Olsltic.:l NtlI1h~i1:;,r nl~n~
<br />160 G<JY~rnmenl~1 CM'r., ."V" 'I:l:o!.~ O"ymr..dQw~ Way
<br />S",l.. B200
<br />"'!l1'\9.c-cla FI. 32501 Jl'1C".k~n"lII.. rl J2l5u
<br />n~o..!)9~-e360 90A 44U...4:~O()
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<br />Central U,a~i<:l
<br />331n M"n'Jlrll BlvU..
<br />Svilel:J:I
<br />Oil.., oUu F'L 3'P.o:~
<br />.n'....!"14-1S55
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<br />$nlrtnWi!'tl District ~wUI~:o1 OililtirJ SOulh Olslnrt
<br />~IUV4 COWuJI Palm nrfV(~ Arm NOM Congress Av. . .22Y'& Vi....u. in ^vc
<br />SUllO 361
<br />Tempa rL. :l:l(;"~ W P<lllll !lcuCll ~L 33.16 rnrt MV"'~, ~L 33901
<br />ijlJ-/11-6100 561-Eie1-l'A',OO 941 33.?.<'l!li5
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<br />MtWitthon BranCh OlTiCe
<br />77~ Ovr.r!\~$ Hwv
<br />S",1..221
<br />Marmon n 33050
<br />.tO~.;IH!t-:nlf'
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