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KEEPING YOU ORGANIZED
No. 12134
2-153LGN
MIN.RECYCLED
INITIATIVE CONTENT M
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TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWN/ERJ AND I�N}STALLER INFORMATION
ADDRESS: ./ r A MAP NO. t 3 PARCEL NO.
OWNER NAME: Al-IMAA ADO i 1 t!/1/ -) VILLAGE:
INSTALLATION DATE: BY..:
4. ADDRESS: l� CERT. NO.
l !QIV 6, 0 Z/p r CA616 TANK INFORMATION
LOCATION OF TANK:
CAPACITY MOO TYPE �fr L_ AGE �Ur' FUEL/CHEMICAL l PO -t OIL
TESTING CERTIF`I-CATION C I PASS E I FAIL DATE
LEAK DETECTION EX7 CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION E ] YES E ] NO DATE TO BE REMOVED
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FIRE DEPT. PERMIT ISSUED YES I I NO DATE i 7
UUNSERVATION I CHECK IF N/A DATE
BOARD OF HEALTH TAG NO. !Ox 7C ]C 3E 7 DATE (11�
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
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CENTEFMLLE OSTERVILLE MARSTONS MILLS FIRE DISTRICT
UNDERGROUND TANK REGISTRY PROGRAM
Owner of Property: 0a M,0 tea) Date of Installation:
Address: ,'-m 9/),.
Description: K Installer: 0 h '
Size: Certification:
Location of Tank: y;w✓'
INSPECTION INFORMATION DATE COMPLETED BY
Site Inspection
Air Test on Tank—Above Ground
Air Test on Tank—Within Hole
Test on Piping
Cathodic Protection Test
Continuous Monitoring System Type
' Backfill Operations i
d - Vent and Fill Pipes
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