HomeMy WebLinkAbout0104 OLD KINGS ROAD - Health (2) /1(o Ola°
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x TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL_ STORAGE l� REGISTRATION!
OWNER AND INSTALLER INFORMATION
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ADDRESS: il ln 'rsa�r",, MAP NO. O PARCEL NO. C
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OWNER NAME: -``. �f ✓Cj VILLAGE: t? u
INSTALLATION DATE: 9 BY:
ADDRESS: J CERT. NO.
TANK I-'NFOR MAT I ON
LOCATION OF TANK:
CAPACI Y i T?Ilr .__. TYPE AGES_ FUEL/CHEMICAL
TESTING CERTIFICATION C J `PASS C J FAIL DATE
LEAK DETECTION *13
CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION C J YES C,XJ NO DATE TO BE REMOVED I/
FIRE DEPT. PERMIT ISSUED C J YES C�J NO DATE
CUNSERVATION C 1 CHECK IF N/A DATE
BOARD OF HEALTH TAG NO. 6-3C JC JC JC J DATE ! '
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD.
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