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UPC 12143
No.
HASTINGS,WN
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TOWN OF BARNSTABLE — UNDERGROUND~FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION J
ADDRESS: _ �A t4 C I fP--6! 1 MAP NO. 7, PARCEL NO. tc3 `
OWNER NAME: aA F I l tl� �`; [mot .� ,� VILLAGE: r3rrk
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INSTALLATION DATE:- BY:
ADDRESS:. CERT. NO.
n ,J TANK' INFORMATION
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LOCATION OF TANK: _ -67
CAPACITY 1VV0 .TYPE AGE I�—, FUEL/CHEMICALaC. rtkL.,.. 0I L,
TESTING CERTIFICATION T J PASS C J FAIL DATE
LEAK DETECTION C� CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION C J YES C ! NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED C ] YES C ] NO DATE .�t1
CONSERVATION C4] CHECK IF N/A DATE s
BOARD OF HEALTH TAG///���NO. 7T 7 C ]C J C 7 DATE 1 �
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PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD