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TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL/STORAGE REGISTRATION ~
SUj OWNER AND INSTALLER INFORMATION
l j MAP NO. b PARCEL NO. 8
ADDRESS: .a lit .Ate(
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OWNER NAME: l 6..��1 K VILLAGE.
INSTALLATION DATE: /BY:
A D RESS:. c6t4 .� l `- ` ' CERT. NO. t ~
N6 a r�,vf TANKeINFORMATION
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LOCATION OFF TANK-.-.
CAPACITY TYPE AGE 1/".FUEL/CHEMICAL lC" 1,
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TESTING CERTIFICATION C ] PASS C ] FAIL DATE
LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND a QC
ZONE OF CONTRIBU ION C I YES X] NO DATE TO BE REMOVED / / /
FIRE DEPT. PERMIT ISSUED C I YES C J NO DATE
CUNSERVATION C J CHECK IF N/A fY DATE
BOARD OF HEALTH TAG NO. 0 e?
71 ]C 7C 7 DATE
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
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