HomeMy WebLinkAbout0027 PILGRIM LANE - Health 27 Pilgrim 'W
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TOWN OF BARNSTABLE — UNDERGRUUND FUEL AND CHEMICAL;_ STORAGE REGISTRATISy
MAP NO.' l PARCEL NO. 1 ( ,� TAG _N0.
=ADDRESS OF TANK1• C) `Z '
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-MAILING ADDRESS ( IF DIFFERENT FROM ABOVE )
OWNER NAME: { ,r .l f=� �, J_ ;`; <<' (':ri'r 3 PHONE:
INSTALLATION DATE: By.
INSTALLER ADDRESS: CERT.NO.
-_ ATI'ON.: ABOVE .STANK LOC BELW Cs CZ:C3_.N
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"`'K f`D COO'RV S`aC' T i NIC `.-LOC/iT 2 OIV7-x
TN1\QOIQCTO >USLD2NCAPACITY TYPE OF ,TANK �' zi °t: t� AGE RS. FUEL/CHEM I CAL; ------•R-" '}
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TESTING CERTIFICATION [ ] PASS [ ] FAIL DATE
LEAK,DETECTION [ ] CHECK IF N/A TYPE/BRAND -
ZONE OF CONTRIBUTION [WYES [ ] NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED [ ] YES [ ] NO - DATE
CONSERVATION [ ] CHECK IF /Fj ,DATE
BOARD OF HEALTH TAG NO. [ ] DATE
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PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE -BACK OF"THIS CARD
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