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-- TOWN OF BARNSTABLE - ,,UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION Ito"'
ADDRESS: ( C .Sa A ,i,- 120A ct MAP NO. PARCEL NO. }�1)
OWNER NAME: �-i'T " f . V I LLAGE'e: N 1 fr�2�� 1 Q_A
INSTALLATION DATE:
ADDRESS: ;+ , CERT. NO;r�-
{ TANK INFORMATION
' LOCATION OF TANK: No tl- s�
:ks• 'CAPACITY TYPE S. L'�A6E�� UEL/CHEMICAL Tt�
TESTING CERTIFICATION C ] PASS C ] FAIL . 'DATE
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LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION [',"AYES [X NO DATE TO BE REMOVED J/t
FIRE DEPT. PERMIT ISSUED C ] YES C ] NO DATE a'
CONSERVATION EX CHECK, IF N/A DATE
BOARD OF.-HEALTH TAG NOf C ]C ]C : ]C ] DATE
_ PLEASE PROVIDE A SKETCH SHOWI�NG`THE' TANK LOCATION ON. THE BACK OF THIS CARD
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