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UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS V/ (�V AY
ASSESSORS MAP NO. 72 PARCEL NON(v
ADDRESS; -15F40 Ni �� 13-4-1 Ro VILLAGE
NAME!--
CONTACT PERSON PHONE NUMBER -X - a & Z
LOCATION OF TANKS:. . ': CAPACITY: ..TYPE- OF- FUEL. AGE: TYPE: LEAK
OR CHEMICAL: DETECTION
SYSTEM!
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DATE OF PURCHASE OF EACH: 1.tvc(p.S- (v(o 2. 3. 4. 5.
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD.
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