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TOWN OF HARNSTABLE FU AND C MICAL STORAGE REGISTRATION
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OWNER AND INSTALLER INF MATION
ADDRESS: D '� �� �-- ►��-�= rt 7- MAP NO.
O. Cry PARCEL NO. /
OWNER NAME: i 1 �'= nr `mot 1� 4t I- -A VILLAGE: 2"o ►�(I �' f
INSTALLATION DATE: t� ` 0 BY: I-- t- �'M �� ^y t-c-r�- S
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ADDRESS: 3�'A, S -r D Al5 CERT. NO.
p f O hJ j , � rV p TANK INFORMATION
LOCATION OF TANK: V 6tuv it 10 ' s r Al r W
CAPACITY I-� � ,i TYPE t Y`✓�'" AGE (lR. FUEL/CHEMICAL
TESTING CERTIFItCATION C ] PASS C ]-.FAIL DATE - 6
LEAK DETECTION C)G] CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION C ] YES C7 NO DATE TO BE REMOVED
:.FIRE DEPT. PERMIT ISSUED L ] YES C ] NO DATE o h ' I
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CUNSERVATION C ] CHECK F N/A DATE a
BOARD OF HEALTH TAG NO. 6 C ]C ]C ]C ] DATE
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PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
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COTUIT FIRE DEPARTMENT
PERMIT FOR STORAGE OF FUEL OIL KOO
In accordance with provisions of Chapter 148, G. L., and Regulations
made under authority thereof. �`y �►9
Name .. 4.. ..'!e�1..C'../..✓.9C!1 !/..11� Name S7C�J/1C�1... � AI�!('1/ l�
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o er or occupa�t) C� (Installer) �1
Address ..C�VCI... .. A...7....U' ...... Address a6 /
C �urner Stowage
Make ..........!4.! ...... ......f1...................... Type of TankS�....,?T�4.�....�IVAI...,�
Manufacturer• ...... ................... Capacity ..t��c...... gals. (or) Size..a7y .
Model No. or Size ...... ................... location ..�? ',...CQ�.�� .....Q `5.r lC
Type,........... .. Mass. Approval No. ...............
Permit issued G
ad of re Department
............................................
By . ..... .
(THIS PERMIT MUST BE CONSPICUOUSLY POSTED UPON THE PRIMISES)
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AA 6'X 4+
g�
P� 6 /'-7/$8
LCR TANK SERVICES, INC.
P.O. Box 765
MARSTONS MILLS, MA 02648
(617) 420-3365
CUSTOMER'S ORDER NO. PHONE DATE
NAME
• --.--GAS V_._ -_-____ /
-- �o--------- -
SOLD BY CASH C.O.D. CHARGE ON ACCT. MDSE.RE 'D. PAID OUT
1'b QTY tDESCRIf?TIdN PRICE,
J -- - ...................------- -_..__..-.
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a RECEIVED By
• TOTAL ���I�•�
All claims and returned goods
1004 MUST be accompanied by this bill.
PRODUCT 610 �