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UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS `'/✓
ASSESSORS MAP NO. ;`3® PARCEL N0. -.
ADDRESS; l 3 %(�/iU I ®1' Old A IO�� VILLAGE �0?/ 5,�V
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CONTACT PERSON �,����� �� /� PHONE NUMBER
LOCATION OF TANKS; CAPACITY: .TYPE- OF- FUEL AGE: TYPE: LEAK
�, OR CHEMICAL. q` DETECTION
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DATE OF PURCHASE OF EACH: 1. ,L" / 2. 3. 4. 5.
DATE OF FIRE DEPARTMENT PERMIT: I w
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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