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p . TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION r r_ s
,ADDRESS: 7' i - / t t . { t1;� MAP NO. PARCEL NO. r I a
OWNER NAME: (���t' 1 /:". � �'i.VILLAGE: <'':�
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INSTALLATION DATE: I rl -7 7 BY: } # ' '
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ADDRESS: I 1: (t ".t , t i `i r;1•/t� !`� .-k CERT. NO.
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TANK INFORMATIONt, ,�l
LOCATION OF TANK:, v
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CAPACITY �� f�� 3tti� TYPE ` �7" ., /.0 AGE Iff 1,'f.= ,FUEL/CHEMICAL //t't',l
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TESTING CERTIFICATION E I PASS, E I FAIL DATE
LEAK DETECTION E 7 CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION E I YES E I NO DATE TO BE REMOVED '
FIRE DEPT. PERMIT ISSUED E I YES E I NO DATE ,
CUNSERVAiION E" ] CHECK IF N/A DATE
BOARD OF HEALTH TAG NOy1f
E"'"' 31 ]E. ]E ] DATE
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PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
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CENTERVILLE OSTERVILLE MARSTONS MILLS FIRE DISTRICT
UNDERGROUND TANK REGISTRY PROGRAM
Owner of Property: �� 0 S f Date of Installation:
Address: C, \
Description: S �� e. Installer:
Size: 5 Certification:
Location of Tank: Xr-7
INSPECTION INFORMATION DATE COMPLETED BY
Site Inspection
Air Test on Tank—Above Ground
Air Test on Tank—Within Hole
Test on Piping
Cathodic Protection Test
'Continuous Monitoring System Type
Backfill Operations
Vent and Fill Pipes
Other: