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•TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
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OWNER AND INSTALLER INFORMATION
lADDRE S: .•Qr� y !?.h"�' t^ f MAP NO. II PARCEL NO
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OWNER NAME: C "f�rnnl'. c� t 9r`;-ft VILLAGE: Stc15?
INSTALLATION DATE: i J "I �BY:
ADDRESS: /k CERT. NO.
co Nfboo�_ TA K,,I NFORMAT I ON,
LOCATION OF TANK: .
CAPAC I TY , Qno TYPE- 3 A E ' FUEL/CHEM I CAL F i
*' TESTING CERT I F I CATION C 7 PASS C ']�_FA I L DATE
LEAK DETECTION C ] :CHECK IF N/A TYPE/BRAND
ZONE, OF CONTRIBUTION- C ] YES.,., C NO DATE TO BE°,,REMOVED
FIRE DEPT. PERMIT ISSUED Cam-3 YES 1 C ] NO DATE '
`CONSERVATION C CHECK IF N/A DATE t
BOARD OF HEALTH T'AG NO. ` 3E `]C 3C ] DATE
PLEASE PROVIDE A SKETCH, SHOWING THE TANK -LOCATIONyON THE BACK OF THIS CARD
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