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110 BRIDGE ST4 OSTERVILLE
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TOWN OF BARNSTABLE — UNDERGRUUND FUEL AND CHEMICAL STORAGE REGIISTRAT_ION,
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MAP NO. PARCELS NO. f �,� "IJ�T�AG NO. �
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y ADDRESS.. OF TANK �p: Y 1Cc �' r- ___ _VILLAGE,:
MAILING ADDRES:S,,(,IF DIFFERENT' FROM ABOVE ) :
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OWNER NAME:. �l `)�) '� HONE: '
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INSTALLATION DATE: BY:
INSTALLER ,ADDRESS: —, "� -CERT.NO. t^
*TANK LOCATION e- `ABOVE" "tELOW -
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CAPACITY s:V'jYPE OF `TANK AGE YRS. FUEL/CHEMICAL E .
' TESTING CERTIFICATION ' [ ] PASS [ ] FAIL DATE fY k 1
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LEAK DETECTION [ ]��,CHECK; IF, N/A ., vTYPE/BRAND
ZONE OF CONTRIBU IONS [ ] YES [ N&\, DATE TO BE REMOVED #e
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FIRE DEPT. PERMIT ISSUED [ ] YES [ ] NO DATE
CONSERVATION [ ] CHECK IF N/A DATE
BOARD OF HEALTH TAG NO. ] DATE
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACX,r 0F,`T,H IS CARD . 1
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