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TOWN OF 'BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION
ADDRESS: / sr )q A MAP NO. PARCEL NO. 115�
VILLAGE:
OWNER NAME: #" ' / ,µ
INSTALLATION DATE: -BY: .--
ADDRESS: _. _ _CERT.- NO....
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�. TANK INFORMATION '. .
;LOCATION OF, TANK: 1 J • �,,�.
CAPACITY t - t!2 TYRE #r" AGEP!1,+" FUEL/CHEM I CAL' n
TEST'I NG CERTI F I CATION DATE
LEAK DETECTION C 7 eCHE K IF� N/A w '`TYPE/BRAND
ZONE OF CONTRIBUTION, C I YES [',NO DATE TO BE REMOVED lqqs3
FIRE DEPT. PERMIT ISSUED C ] YES Ch] NO DATE
UUNSERVATION C I CHECK IF N/A DATE
BOARD OF HEALTH TAG NO. C L, I C I C I C ] DATE
PLEASE PROVIDE A SKETCH SHOWING THE .TIK" LOCATION ON THE BACK OF THIS CARD
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