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TOWN OF -BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION L1 '8 ' '� 0D
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ADDRESS: 'Cf 't y .«iC'Si'_ _.. _. ,MAP NO.._() 'PARCEL NO. C) l ��
OWNER NAME: -f' f(at-T\eJC_ VILLAGE: QS r"\J 1 11 o ,
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BY: 1C! %"f�pl�Jtr .ti. �c d
ro- ,'`"`-INSTALLATION DATE:., . j2
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ADDRESS: CERT. NO.
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C r � TANK INFORI ION
LOCATION OF� TANK: r-# ,i o
CAPACITY 1 .�3Cah TYPE �'s�C / AGE r,,7 (FUEL/CHEMICAL" '" C 1
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TESTING CERTIFICATION C I PASS C I FAIL I DATE
LEAK DETECTION C I CHECK IF N/A TYPE/BRAND
'. ZONE OF CONTRI-BUT.ION C ] YES C NO . DATE TO BE REMOVED
FIRE DEPT" PERMIT ISSUED C J YES C ] NO-,,,-.DATE-
CONSERVATION C ] CHECK IF N/A DATE t
BOARD OF HEALTH, TAG NO. C ] 31 31 ]C ] DATE / 1
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK. OFjTHIS CARD
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TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGIS�TyRATIGO�N�
OWNER SAND INSTALLER INFORMATION �p�G �,�t 1 ti►�
ADDRESS: pi
MAP NO. PARCEL NO.
OWNER NAME: 7 /I G 46 �� ��/ c3. &M6�AVILLA.E:
INSTALLATION DATE: cw—toy:
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ADDRESS: CERT. ' NO.
TANK INFORMATION
LOCATION OF TANK:
CAPACITY 500 TYPE / i..�- AGE �� FUEL/CHEMICAL V C--
TESTING CERTIFICATION C I PASS C I FAIL DATE
LEAK DETECTION C I CHECK IF N/A a TYPE/BRAND
ZONE OF CONTRIBUTION C 7 YES 7 NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED C ] YES C I NO DATE . ,
CONSERVATION C I CHECK IF N/A DATE
BOARD OF HEALTH TAG NO. qj� 71 ]C ]C J DATE
PLEASE', PROVIDE;A SKETCH SHOWING THE: TANK LOCATION ON THE BACK OF THIS CARD.
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