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s.. -TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
n OWN/ER AND INSTALLER INFORMATION
ADDRESS:__ ( �t L � MAP NO. PARCEL NO. N7
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OWNER NAME: �I C t 1'e n SULPM P. R106X ..VILLAGE: 1 .�C a� V I G
INSTALLATION DATE: BY:
ADDRESS: `� CERT. NO.
No�� a 17/"U� i rt r TANK INFORMATION
LOCATION OF TANK: OAS-r 60 Or P 0LE t SQ L A OF
CAPACITY TYPENSAGE FUEL/CHEMICAL rila OIL.
TESTING CERTIFICATION E I PASS E ] FAIL DATE
LEAK DETECTION EA CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION E I YES E4 NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED E I YES E)] NO DATE
CUNSERVAIION E I CHECK IF N/A DATE �}r
BOARD OF HEALTH TAG NO. gll]E ]E ]E ]E ] DATE
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD J
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;- TOWN OF BARNSTABLE /1C�V
UNDERGROUND FUEL AND CHEMICAL STORAGE
SYSTEMS
ASSESSORS MAP NO. PARCEL N0. !,4 7- J,l4n
ADDRESS: f'O t,rs�yrr�e VILLAGE (®e✓trJt((�2 1 /NLQsS
CONTACT PERSON c �� -C// PHONE NUMBER 'I7/-897�7
LOCATION OF TANKS:. . CAPACITY: ..TYPE OF- FUEL.' AGE: TYPE: LEAK
g j f _ OR CHEMICAL - - DETECTION
;�� Pn a, �✓52 s�� off" - �, �i�� `� 2� SYSTEM'
DATE OF PURCHASE OF EACH: 1. 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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