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TOWN OF BARNSTABLE —. UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
I O,J/�" 6 /j[qj OWNER AND INSTALLER INFORMATION f
ADDRESS: MAP NO. PARCEL NO.
OWNER NAME: / IV VILLAGE: (�',ctillZ t/iLL
INSTALLATION' DATE: S Z— BY:
ADDRESS: b _
TANK IiNFORMATION
LOCATION OF TANK: //4 ' Ccww 2 �^'✓ "i�c� ✓1�
CAPAC I TY TYPE .F7 'L. AGE [ FUEL/CHEM I CAL AICA 0,1
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a TESTING CERTIFICATION C I PASS C ] FAIL DATE
LEAK DETECTION [X CHECK IF N/A TYPE/BRAND,
ZONE OF CONTRIBUTION C I YES C' NO I' DATE TO BE REMOVE-DAM,
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FIRE DEPT. PERMIT ISSUED C-YES C I NO DATE / L `✓E ��'vr+c�
CONSERVATION C/h .CHECK,. IF N/A Y.DATE
BOARD OF HEALTH . TAG NO. C 7 C ]C ]C ] DATE ` h9k, III ._
PLEASE, PROVI'DE ASKETCH SHOWING.;THE .TANK. LOCATION ON THE ,BACK OF THIS CARD
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