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TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION
ADDRESS: ll A'E � MAP NO. PARCEL NO.
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OWNER NAME: U)lq 1)l o �l / VILLAGE:
INSTALLATION DATE: f 1 BY:
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ADDRESS: CERT. NO.
-U Zlo7 TANK INFORMATION
LOCATION OF TANK: 1f'' A in V-i)p/ f' WA �I�U Q/V I �Or e tt' ,:
CAPACITY TYPE � AGE 1 FUEL/CHEMICAL
TESTING CERTIFICA�T/ION C I PASS C I FAIL DATE
-``.LEAK DETECTION / ` CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION C I YES C ] NO DATE TO BE REMOVED C/ f
FIRE DEPT. PERMIT ISSUED C I YES C I NO DATE
CUNSERVATION [ CHECK IF N/A DATE
BOARD OF HEALTH TAG NO. Cqv ]C ]C ]C ] DATE
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
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