HomeMy WebLinkAbout0112 CAP'N SAMADRUS ROAD - Health (2) druS �aLf
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TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
_OWNER AND INSTALLER INFORMATION
ADDRESS: �1f� I !y "L_ 9 Zx C/fa 4. /f,c../ � MAP NO. � PARCEL NO.�
OWNER NAME: % %' ° f r ! !1�' s rW{ r Tp �VILLAGE: ,1 77,
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INSTALLATION DATE: / _ BY:
ADDRESS: �} F CERT. NO.
Tf joil 0 tJ TANK INFORMATION
LOCATION OF TANK: O
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CAPACITYS Q 6 TYP AGE Z FUEL/CHEMICAL d r I
TESTING CERT IF I CAT j O - --[]--PASS-,.-.G-]w:-FA I L--,v DATE
LEAK DETECTION ' CHEC-•K I N)'A*' TYPE/BRAND
ZONE OF CONTI�T;�UTION C ] YES E►�''] NO D,?, DATE TO BE REMOVE % `� 6 C /,�L � �
FIRE . DEPT: PERMIT ISSUED C ] YES C I NO DATE
CONSERVATION C ] CHECK IF N/A DATE
BOARD OF HEALTH TAG NO. C ]C IE' ]C. ] DATE- s`
PLEASE PROVIDE. A: SKETCH SHOWING .THE_;TANK LOCATLON ON ,TW BACK. OF., THIS -;CARD.
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