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HomeMy WebLinkAbout0118 CENTER STREET - Health 118 Center Street Sewer Acct # 4236 Hyannis i A = 327 -039 Make application to local Fire Department. Fire Department retains original application and issues duplicate as Per �aWVrna�ni�ea��� jv e �firn�rrta� �Vtlicea— ✓c�aaa�o�C�axe i ca�rr APPLICATION and PERM Fee: for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by: • Tank Owner Name(please print)( , lI0 I x lSignature i aptlyrngrorpermrtf Address S f 1 S ol 4- Street city Stare Tip 7Gomp7anyNam4f'-TC F2�Qj-I11�� Co. or Individual Pnnt Pant Address [N/ sin Address Pantt Print Si r (if appl ' for permit) Signature(if applying for permit) IFCI Certified Other IFCI Certified 0 LSP# Other Tank Information AIS& Tank Location 11 R: Ce Alio �vowts py, ���� 0,3,9 / Steer Address city Tank Capacity(gallons) �� ��<lw► Substance Last Stored e--)-- O< Tank Dimensions(diameter x length) Remarks: AwO m F A".64 IAA USA IVIFirm transporting waste State Lic. #_ d J7 Hazardous waste manifest# /If�l E.P.A. # Approved tank disposal yard - y` S Tank yard# Type of inert gas 'fti Tank yard address City or Town A lelt'i7,M/.r FDIO# 't' i dt' Permit# 99586 Date of issue Date of expiration v� hl� t+ _70 '�-n1- Dig safe approval number: A Dig Safe Toll Fr "71. urrib ©0 322-4844 Signature./Title of Officer granting permit �00 +r rzo. After removal(s)send Form FP-290R signed by Local Fire Dept. to UST Regul ory Compliance Unit,One Ashburton Place, Room 1310, Boston, MA 021 08-1 61 8. FP•292(revised 9/96)