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TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
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ADDRESS OF TANK: / 1 7 s o. MAN 's t . V I L L A G E: ( 1 V ! dC V �a
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MAILING ADDRESS ) ( IF DIFFERENT ,,F�(FROM ABOVE) :
OWNER NAME: V ��� I Cry A k L,OV 1 r PHONE:
171
INSTALLATION DATE: BY: w W
INSTALLER ADDRESS: CERT.NO.
*TANK LOCATION: �J�(/��� e
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CAPACITY /00n TYPE OF TANK..&fL, AGE YRS. FUEL/CHEMICAL
TESTING CERTIFICATION [ ] PASS [ ] FAIL DATE ,
LEAK DETECTION [ ] CHECK IF N/A�� TYPE/BRAND
ZONE OF CONTRIBUTION [ ] YES NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED [ ]'YES\ C ] NO DATE
CONSERVATION C ] CHECK IF N/A DATE
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BOARD OF HEALTH TAG N0. [ -f ] DATE �A
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* PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD