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TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATIIOON
ADDRESS: �� Z� * MAP NO. l r` PARCEL NO.
OWNER NAME: `✓� � VILLAGE: ��
INSTALLATION DATE: 7'l/ r~`BY: G .1 f / r
ADDRESS: ( 4�1 CERT. NO.
' TANK INFORMATION
LOCATION OF TAN��
CAPACITY TYPE AGE FUEL/CHEMICAL
TESTING CERTIFICATION C ] PASS C 7 FAIL DATE
LEAK DETECTION [-.- CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION ,J 7 YES C ] NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED EV: YES C 7 NO DATE
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CUNSERVAiION C CHECK IF .N/A DATE
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BOARD OF HEALTH TAG NO. C ]C ]C ]C ] DATE X C'/�'�01
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PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
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