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TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION
ADDRESS: 2 /�S% /'"/[ �, MAP NO. I& PARCEL NO. 0-f /
OWNER NAME: 4/.7 -- —e VILLAGE:
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INSTALLATION DATE: � � ����3� BY: �. �`". A-w?( —+
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ADDRESS: ' CER`T ENO.
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TANK INFORMATION ,
LOCATION OF TANK: / i'UF9c" iA2/`z�Aw
CAPACITY c7 6��RL TYPEr AGE FUEL/CHEMICAL
TESTING CERTIFICATION E ] PASS C ] FAIL DATE
LEAK DETECTION _. E��x] CHECK IF N/A TYPE/BRAND '
ZONE OF CONTRIBUTION C ] YES L ] NO DATE :TO BE REMOVED
FIRE DEPT. PERMIT ISSUED 1! YES C ] NO DATE
CUNSERVATION C CHECK IF N/A DATE
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BOARD OF HEALTH TAG NO. ]C ]C ]C ] DATE WIVID AAIL�—
PLEASE PROVIDE A SKETCH SHOWING THE TANK. LOCATION ON THE BACK OF THIS CARD