HomeMy WebLinkAbout5000 017859 097 01-21-2021 CHIOWN SLA CHANGE IN OWNER 75462.93 4 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: ustcomplianco@adem.alobama.gov
Montgomery,AL 36130-1463 Web Site: adem.alabama.gov
FACILITY INFORMATION
Former Name of Facility: Myers Market Theodore ADEM Facility I.D.
Number.21749-097-017859
Location(street or highway):6960 Theodore Dawes o. s inclu ed n transfer.2
Road
City, County:Theodore, Mobile No.of ASTs include in transfer0
Transfer of Ownership ate: U1/21/2021
FORMER OWNER INFORMATION
Owner Name: Myers 011 Co. Chambliss Group I owner Phone Number: -
Address:221 Commercal Blvd. 202 1 954-938-7211
City, late,Zipe: Lauderdale By The Sea, FL 33308
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NEW OW ER INFORMATION
Owner(Company)Name:JSN Hospitality LLC Contact Name: Chireyu Amin _
Owner Phone Number. (423 ) 5U5-7679 Conrad Phone Number. 23 05-7579
Address:6960 eodore Dawes Road mail: am n mall.mm
City, State,Zip Code:Theodore,AL 36582
Email: ammoclUgmall.ob Name o Faciity:
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REQUIREMENTS
Any person who sells an underground storage tank(UST)or an aboveground storage tank(AST)
system must:
e Notify the Department of transfer of ownership byfully completing thisfonn and returning It to the Departmentwilhln 30 de
from the date of transfer,
• Provide proof of transfer of ownership of the system by signing this form,
Any person who receives ownership of an existing underground storage tank(UST)w• nabovegreand-tit--- - -
tank (AST)system must:
Provide proof of transfer of ownership of the system by signing this farm
Please return the completed form within 30 days of transferring ownership to the Department by mall,
email or fax.
Once the completed farm Is received by the Department,the new owner will receive a letter acknowledging their new ownership.I
letter will be an ADEN Notification for Underground Storage Tanks"form#279 and/or"Notification for Aboveground Storage Tani
#283 that will be partially completed.The new owner should check for accuracy and complete the form,$ION AND DATE the to
submit to the Department within 30 days of receipt. Once this process Is complete,ADEM will send the new owner a copy of I
cemficate to be displayed at the she.
Please Note: If the former owner does not sign this form, you must provide a warranty deed or other approve
documents for proof of ownership.In addition,if there are any unpaid UST regulatory fees due at the time of this trar
ownership,the now owner Is responsible for submitting payment to the Department.
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