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TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION
ADDRESS: Cq.7' � / Cd7&IrMAP NO. PARCEL NO. 4/4
OWNER NAME: -,- '4�/S�IfsV /U1 / / l l VILLAGE: rnn) !
INSTALLATION DATE: 7 - BY:
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jA�.(✓DD(+REA(SS: CERT. NO. 018 A6
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TANK INFORMATION
LOCATION OF TANK: �,�.�Cd 6 °c.�--�,1^.+�� 1� / /a� F W J'A-5—;
CAPAC I TY / TYPE `"� AGE FUEL/CHEMICAL,'r.;
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TESTING CERTIFICATION C ] .PASS - C ] FAIL DATE
LEAK. DETECTION -CHECK IF N%A , TYPE/BRAND
Cx
V rl ZONE OF CONTRIBUTION C ] YES; C NO DATE TO. BE REMOVED
N°
FIRE DEPT. PERMIT ISSUED C,K] YES C ] NO DATE
CONSERVATION C ] CHECK IF N/A DATE i
BOARD OF HEALTH TAG NO. &V
2. 4E ]C ,. ]C ] 'DATE (?
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PLEASE ,PROV I DE,' A SKETCH SHOW LNG THE, TANK, LOCATION. ON ;THE BACK OF. TH I S CARD .'
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