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TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION I ( 1
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ADDRESS: f�'11/I/ �L S L,4' MAP NO. �°�/r�7 PARCEL NO.
OWNER NAME: 0 `� '��1'�� L / ! . I� i�\/ t VILLAGE:
INSTALLATION DATE: 7 �3 � BY: '1056
ADDRESS: CERT. NO. �i' `TJ�� /dkd`✓fIL'�"`!K7
J . t , �- J TANK INFORMATION G
L"OCATION OF, TANK-* /N
CAPACITY,:,-;?0e'0 64Z- TYRE t 5/��G AGE FUEL/CHEMICAL
TESTING CERTIFICATION C 31PASS C ] FAIL DATE
LEAK DETECTION/1 EA CHECK �IF--N/A---- TYPE-/BRAND--- r.—......._- r r
ZONE OF CONTRIBUTION C)(] YES C ] NO DATE TO BE REMOVED ! /�
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FIRE DEPT. PERMIT "I'SSUED C ]-\YES�) ' C 7.. NO. DATE
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I:UNSERVATION C ]CHECK IF N/A DATE_.._ I
BOARD OF HEALTH TAG, YNO. ] ]C �]C ]C7 DATE 1, s,�t7re
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, - PLEASE PROVIDE A SKETCH SHOWING THE_ TANKaLOCATION ON THE BACK OF THIS CARD
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