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TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION !
OWNER AND INSTALLER INFORMATION
ADDRESS: 7 ..2Q lJt !I rK MAR NO. ". PARCEL NO. I
OWNER NAME: Q aid - VILLAGE: Cp T Q 11; 114 Z
INSTALLATION DATE: 12.1 BY: _kn at
ADDRESS: ? G ft t• ' rc, "•p2a CERT. NO.
JtTANK INFORMATION
LOCATION OF TANK:
F * CAPACITY dOQ AGE FUiEj,/CHEMICAL
TESTING CERTIFICATION Cam] PASS C ] FAIL D- TE. STi
LEAK ,DETECTION. C 7..CHECK�IF N/AYP llE/BRAND
ZONE OF CONTRIBUTION I I YES . 0 ] NO" DATE TO BE REMOVED t/ '
FIRE DEPT. PERMIT ISSUED C✓] YES C` I NO DATE 51 E I
CONSERVATION CHECK IF N/A DATE
BOARD OF HEALTH TAG NO. ]C ]C ]C � 7C ] DATE,,-�
PLEASE PROVIDE A SKETCH. SHOWING THE. TANK LOCATION ON THE BACK OF THIS CARD
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