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MASS. S.P.C.A.
CAPE COD BRANCH
1677 FALMOUTH RD.
CENTERVILLE, MA 02632
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t a' TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS Awe
ASSESSORS MAP N0. PARCEL NO.
ADDRESS: Tat Nvx0A4, VILLAGE' '?
NAME',_. ��ss —
to. _ : .`�•�?
CONTACT PERSON PHONE NUMBER r 7`7S "G`j 0
LOCATION OF TANKS: -CAPACITY: TYPE OF FUEL. AGE: TYPE: LEAK
OR CHEMICAL: DETECTION
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DATE OF PURCHASE OF. EACH: 1. 2. 3. 4. 5. -
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
To '6-,gr6a) �
PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF, THIS CARD. ��`
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CENTERVILLE • OSTERVILLE • MARSTONS MILLS FIRE DISTRICT
UNDERGROUND TANK REGISTRY PROGRAM
Owner of Property: S e--C Date of Installation:
Address:
Description:_ Installer: y-7""r�
Size: S �a Certification:
Location of Tank: 4Z17
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:
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FORM FP. 292
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r l Department of Public Safety
Division of Fire Prevention and Regulation
AMJCATION FOa PERMIT, AND PERMIT, FOR REMOVAL AND TRANSPORTATION TO APPROVED TANK YARD
FDID# 01920 Permit # Date September 21 19 92
Centerville
MY,Town at luuwi C . 82 s , 4 R K G . L .
10.00
2 C �� DIG SAFE NUMBER
Fee Paidit 92571074
start date 9/21/92
In accordance with the provisions of Chapter 1480 Sec. 38A, M.G.L. ,
527 CHR 9.00 application is hereby made by: Clean .Harbors
Street Address & City or Town: 85 Allrich, Providence RI
Signature of applicants r
Applicants name printed a
For permission to remove and transport one underground storage tank from.
owner: MCPCA Street Address: 1577 Falmouth Road, Cent.
Clean Harbors
Firm transporting waste: State Lic. # 1A-(W� /
Hazardous waste manifest
Approved tank yards Mid City Scrap Yard # 12889
Tank yard Address a Westport, MA
Type of inert gas! �r�� 1 -- UL tank # •
•
Tank capacity:_ Son_ Substance last stored: #2 Fuel. oil
Date of . issue: September 21, 19 92 Date of expiration: Octo r 5, 92
Signature/Title of officer granting permit: Al
11 ,
KEEP ORIGINAL AS APPLICATION AND ISSUE DUPLICATE AS PERMIT