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TOWN OF BARNSTABLE -- UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
[) L OWNER' AND INSTALLER INFORMATION
ADDRESS: f?,<-4, i. 11� M L�s�� �,c��- �{":ti{'y� � MAP NO.: la.�'r� PA 'CEL NO.
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OWNER WE: VILLAGE:
INSTALLATION
ADDRESS: /fir�,� r . ,��. ri� S ika _ 1� CE,RT. NO.
TANK INFORMATION
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LOCATION OF TANK:
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CAPACITY OUO . �. TYRE t .s it, AGEy 4-atl FUEL/CHEMICAL
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TEST—IYNS-_CERTIFICAT-ION - C ] PASS : C ] --FA-IL
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LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND
F
E OF CONTRIBUTION C ] YES C ] NO, DATE TO BE REM VED
E DEPT T.
PERMIT ISSUED m-C ]... ES..-s4 1 7 NO DATE
CUNSERVATION C ]_ CHECK IF N/A DATE I
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BOARD OF HEALTH TAG NO. ]C ]C ]C ] DATE M f W�) )
PLEASE PROVIDE, A SKETCH SHOWING THE TANK LOCATION ON .THE BACK OF THIS CARD
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