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TOWN OF BARNSTABLE—UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION
ADDRESS: & MAP NO. PARCEL NO. _
OWNER NAME: !t J i VILLAGE:
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INSTALLATION DATE: BYTE
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ADDRESS: .il .a.;, CERT. NO. `
PPP��r f / 0 l TANK INFORMATION ry
LOCATION OF TANK: J tS - `" -Z F-& Nam.
CAPACITY :560 TYPE k 1 AGE Z FUEL/CHEMICAL
TESTING .CERTIFICATIIOON E ] ;PASS E I FAIL DATE
LEAK DETECTION IV3 CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION E I YES E� NO DATE TO BE REMOVED
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FIRE DEPT. .PERMIT ISSUED E:V,I YES E ] NO DATE Z6 F 'AAA
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CUNSERVA?ION E ] CHECK IF N/A DATE t
q,tBOARD OF HEALTH TAG NO-OWE ]E ]E lC ] . DATE(✓
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
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