HomeMy WebLinkAbout0171 CAP'N CROSBY ROAD - HAZMAT 17/ Ca-� ��' Crams 1� R-C)W ,
TOWN OF BARNSTABLE
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS
NAME
ADDRESS /�1/ C1 ,�� C�r�s�1�P�� VILLAGE �-
LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE:
OR CHEMICAL
ve
(Give same information for any additional tanks on reverse side of card)
DATE OF PURCHASE OF EACH: 1. 2. 3. 4.
DATE OF FIRE DEPARTMENT PERMIT: _ X�'e-%L
TESTING CERTIFICATION SUBMITTED: /
PASSED y DID NOT PASS
TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION
ADDRESS: / 7 / <<D ! l /is d. f r r)`;�t� ��! � MAP NO. 19 .9 PARCEL NO.
OWNER NAME: �rCItJ�YG' ! A (l ii
1
INSTALLATION DATE: BY:
ADDRESS: CERT. NO.
--------------------
TANK INFORMATION
LOCATION OF TANK:- c h9 r(t s l'
CAPACITY 11200 TYPE E�� AGE t FUEL/CHEMICAL old
TESTING CERTIFICATION C ] PASS C ]• FAIL DATE
LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION , C ] YES CX] NO DATE TO BE REMOVED Q
FIRE DEPT. PERMIT ISSUED C ] YES C ] NO DATE
UUNSERVATION C ] CHECK
IF N/A DATE
BOARD OF HEALTH TAG NO. C/�]'JC ]C ]C ]C ] DATE / �Z
PLEASE PROVIDE A SKETCH/ SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
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