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TOWN OF BARNSTABLEeoi
UNDERGROUND FUEL AND CHEMICAL, STORAGE SYSTEMS � 1✓V .
ASSESSORS MAP NO. a/ 0 PARCEL NO. V �.
ADDRESS,' 3 (2C_L L_ c VILLAGE
NAME
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CONTACT PERSON� 0-7 �} � PHONE NUMBER
LOCATION OF TANKS: CAPACITY: .TYPE OF FUEL AGE: TYPE: LEAK
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I,, _ OR CH MI ALP DETECTION
SYSTEM!al �NFO
DATE OF PURCHASE OF EACH: 1. ,. 3. 4. 5.
DATE OF FIRE DEPARTMENT PERMIT: '
TESTING CERTIFICATION SUBMITTED: /e) PASSED ✓ DID NOT PASS
PLEASE PROVIDE A SKETCH SHOWING TIIE LOCATION OF TANKS ON THE BACK OF THIS CARD.
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TOWN '.OF BARNSTABLE, MASS. r(1
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(APPROXIMATE SIZE)
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(STREET AND NUMBER)
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NAME OF BUILDER+OR CONTRACTOR ;
aD APPROXIMATE COST:
i HEREBY AGREE TO CONFORM TO ALL THE RULES AND REGULATIONS OF.THE TOWNQ
cM>m OF BARNSTABLE, REGARDING THE ABOVE CONSTRUCTION.
(OWNER) ««..««.»...«..........................«.............«... «.«........««...
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Sewage -4`207
NG'INSPECTOR
Sullied to Approval of Board of Health..
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