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Home My WebLink About5756 006292 081 05-22-2020 CHIOWN SLA CHANGE IN OWNER 63384.21 CHIOWN ADEM UNDERGROUND AND ABOVEGROUND STORAGE TANK TRANSFER OF OWNERSHIP FORM Alabama Dept. of Environmental Management Phone # (334) 270-5655 Groundwater Branch/Land Division Fax# (334) 270-5631 P. O. Box 301463 E-mail: ustcompliance@adem.alabama.gov Montgomery, AL 361 3 0-1 463 Web Site: adem.alabama.gov FACILITY INFORMATION Former Name of Facility: ADEM Facility I.D. Number: ,2 Y - OS/- O2) Location street or hi hwa : li No. of USTs included in transfer: City, Goun : I No. of ASTs included in transfer: Transfer of Ownership Dat . 10/ p / ;74I 19 FORMER OWNER INFORMATION Owner Name: Owner Phone Number: et 8 Address: µ City, State, Zi Code: - t certify under penalty of law then 1 am familiar Ith the above information,and I believe that this Information Is tme,accurate and complete. Signature of former owner Data: V NEW OWNER INFORMATION Owner (Company) Name: - +,4A C 1 G Contact Name: .h Owner Phone Number: 1 1 Contact Phone Number: Address: a2ot5 371 S 1.` _ Contact Email: r a� City, State, ZipCode: }),1A.. L 4 Company Email: CLoo, .. New Name of Facili 1 certify under penalty of law that I am famllla wiKM I on,and I believe that this information is We,accurate aW compkta. Si nature of new owner: - Date: REQUIREMENTS Any person who sells an underground storage tank (UST) or an aboveground storage tank(AST) system must: M a Notify the Department of transfer of ownership by fully completing this form and returning it to the Departe Ohin 30 days from the date of transfer, �yEC y • Provide proof of transfer of ownership of the system by signing this form, ? a Any person who receives ownership of an existing underground storage tank (UST) or a",bovegrou4 storage tank (AST) system must: of "e Provide proof of transfer of ownership of the system by signing this form ND W P Please return the completed form within 30 days of transferring ownership to the Department by mail, email or fax. Once the completed form is received by the Department,the new owner will receive a letter acknowledging their new ownership. With the letter will be an ADEM "Notification for Underground Storage Tanks"form#279 and/or"Notification for Aboveground Storage Tanks"form#283 that will be partially completed.The new owner should check for accuracy and complete the form, SIGN AND DATE the form, and submit to the Department within 30 days of receipt. Once this process is complete, ADEM will send the new owner a copy of the tank certificate to be displayed at the site. Please Note: If the former owner does not sign this form, you must provide a warranty deed or other approved legal documents for proof of ownership. In addition, if there are any unpaid UST regulatory fees due at the time of this transfer of ownership,the new owner is responsible for submitting payment to the Department. ADEM Form 469 010 m2(revised 3118) FACILITY I.D. NUMBER: rI � - VO) - Oblp/'. REGINP Rd:C ADEM NOTICE OF UNDERGROUND STORAGE TANK UST COMPLIANCE INSPECTION ADEM,id.,.J.CMe RWe JJS615 Cwn iawa In Avf d.r.bn 3]S61S bA�Fx bRxatlx Anyowmrdopa'elorWsn urnMgmuM 51weW fenkdMll u(Cn mqueSlWe NUyeNImYmO mpreaenlelrvBW Me OBWmnenl.Ponnrt MB TpABBntBiM.B!ellmaaonede lvnea, m aN,emNa mncem Me st o/ WBMISWYm95eM m.AMe masntetrveb N4 AW,W JJSE-I✓.<f Enfry eM nawclpn a/FB[Ila¢a, pray OwmlwpPo�Btwplen unEegmuM sb, etankaM1ell ulam/WBBatWetlWy BulhP'ixtl2preaenletivB dMe oeperlmenl,pemml Me repaasnRtrvnrombr, RoutineC re5 ns ecti ay.Tem fin,mEe mute efwe a for o ce nape on b I/aN.11Ba BnO u meet MtlMOMMttrBon Bntl58m tin . Routine Com liance Inspection Prior Notice ins coon FOIIowU In 'on from: / I Owner Name N #of USTs Mailin Address 381 Lee 2 FacilityName kfs 'D; ac: City',,Jh5 5 a n State AL Zi Street Address 1,T2u L.Cf QA TEA Owner Email Address I County t,4/. City(Nearest) m1 S u• Submll Desl natetl Notlflca ohs ❑Suspected Permanent ❑Temporary New installation Trensfer of Notlfioatbn Other Release(form 480) closure(form 422) closure(form 310) or upgrade(corm 423) ownership(form 469) (forth 279) Submit Designated Regulatory Fees USTregulatoryfeepaymemduefoc ❑Curentflscel year ❑Pnorgscalyears,specil Submit Designated Delinquent Test Reports Annual line tightness test (0.1 GPH)(form 477) Annual test of automatic line leak detector(form 551) ❑Annual SIR 30 day results summary(form 326) ❑3 year Catchment basin(spill bucket)test(forth 20) ❑3 year UST impressed current cathodic protection test,(form 332) [3 3 year containment sump integrity lest(torte 567) ❑3 year Piping impressed current cathodic protection test(form 332) ❑Annual probes and sensor:test(form 560) 03 War gi cathodic prictecdon test torte 545 ❑Other: Submit Most Recent Design ted Additional Test Data day ATG 0.2 gph test printout 30 day tank interstitial sensor printout 030 day CSLD test printout_ 030 day manual interstitial monitoring log(form 406) 030 day SIR report log(lore 326) ❑Electronic line leak detector 3.0 gph test printout ❑Annual release detection equipment testing log(form 561) []Monthly electronic line leak detector 0.2 gph test pnmoul ❑30 day containment sump sensor printout []Annual electronic line leak detector 0.1 gph test printout ❑30 day manual tank gauging log(to.563 ❑Other: Submit Designated Operation and Maintenance Inspection Results 60 day impressed Current CP Inspection Log(torte 400) ❑Annual walklhro igh inspection log(ton 19) ❑3 War overfill prevention inspection forth 559 []Monthly walkthrou h inspection I form 558 Operadon and Maintenance Needing Immediate Action Containment Sumps Containment Sumo Eauipment Operator Training ❑Empty water&property maintain sump(s) ❑Properly position sump sensor(s) ❑Submit A-S operator training record []Empty fuel or fuellwater mix,dispose of property& []Sump sensor must shut off sub pump ❑Submit C operator training record properly maintain sump(s) []Clear fuel alarm from sump sensors) Compatibllgv [_]Repair sumps and/or sump equipment as necessary ❑Replace missing line leak detectors) ❑Submit missing compatibility logs to prevent liquid from entering sumps ❑Replace deteriorated flexible piping TermporaN Closed Tanks Tank Cathodic Protection Rectifier Spill Prevention Eguipmem InPerform leak detection ❑No amps or vows-restore power or fix meter ❑Remove fuel/water-dispose of property ❑Monitor corrosion protection every 60 days []Amps reading too low-re a r system&retest ❑Repair lama ed still catchment basin a []Remove mkn2[a[M contents W 1 inch or lees Inspector Comments; rt a ur B.er a lip yq('Ss�f4 pfie,,5f. pnAlig gort owe1"g -7-14 - L4611 _ Z Ir NNW M: .1 <, 'l s5 n Submit any requested information to the attention of the inspector at the address indicated below,fax to the inspector's attention, ore-ma�/ff to the Inspector at: t/'tP"J.bgve:s4 @adem.alabama.gov ADEMpFreld OpereGans❑Land E ❑Bi 'rig m 'eltl w ❑ obi Fie A M fur Id ce ,-, Divisi Din P.O.Box 30/463 1 d ke 22 Pe • Rd. 5 R S. I Montgomery Alabama 36/30.1463 i h la a 5 0 Ie A b a 6 1 u la ma 33v Phorre/Faz# 334 - 51a2 Ph Phoneffax t 2 i PWna/Fax# 256 Cons liana Inspection Results Lj No Action Required-Thank you for our continuin aeons to cons with the ADEM UST ulations. Additional Information Banque;— ❑ Delinquent Information Required ❑Immediate Action Required within 24 hours Submit requested informatiowconfirmation to ADEM within 7 days. Failure to submit the requested information could result in enforcement actions and penalties,as well as this facility being prohibited from delivery by the Department through placement on the Department's Delive Prohibition Web 't NOTE: THE ABOVE FACILITY WAS INSPECTED TO DETERMINE COMPLIANCE WITH ADEM ADMINISTRATIVE CODE RULE 335 15. THE OF COMPLIANCE IS INDICATED ABOVE. XcNft Receipt of the`ADEM UST Compliance Inspection-is hereby acknowledged by the facility owner or representative. N otiwr than the owner racsivea this notice,It should immediately be forwarded to the owner of the USTs 3 ZOZO Spun C1 7S prc•n G1 Signature of Owner or Representative Data P ;ure of Ina ector Ins erl:. JfRNt S 3(Own:n Oale 'tit WEEP ADEM FORM 286 7712 m2 sed 18) TO COPY-FILE BOTTOM COPY ❑supplement Page 2 Competed STOP IN-TANK LEAK TEST T I :PREMIUM 24-05-20 4:01 HEARNS GROC 24-05-20 4:01 LEAK TEST REPORT T I :PREMIUM PROBE SERIAL I4UN 111998 TEST STARTING TIME: 24-05-20 0:01 TEST LENGTH = 4.0 HRS STRT VOLUME = 3913.3 GAL LEAK TEST RESULTS 0.20 GALHR TEST PASS STOP IN-TANK LEAK TEST T 2:REGULAR 24-05-20 4:01 HEARNS GROC 24-05-20 4:01 LEAK TEST REPORT T 2:REGULAR PROBE SERIAL NUM 200672 TEST STARTING TIME: 24-05-20 0:01 TEST LENGTH - 4.0 HRS STRT VOLUME - 3959.1 GAL LEAK TEST RESULTS 0.20 GAL:HR TEST PASS