HomeMy WebLinkAbout0121 CHASE STREET - HAZMAT 3D I -
TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
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OWNER AND INSTALLER INFORMATION
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ADDRESS: ��1 / .e� 4 S`� �5� � ' r .r�- MAP NO. / a
OWNER NAME: VILLAGE: - .•M--�
INSTALLATION DATE: BY:
ADDRESS: CERT. NO.
O / TANK INFORMATION..
LOCATION OF TANK:
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CAPACITY .,,),TYPE-- U�� ' AGE- - FUEL/CHEM-I CAL- � � - _•<-
TESTING CERTIFICATION C I PASS C I FAIL DATE f'
LEAK DETECTION C* CHECK IF N/A TYPE/BRAND '
ZONE OF CONTRIBUTION; [ I YES CY ] NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED C 7 YES C I NO DATE
CONSERVATION C ] CHECK IF N/A. DATE
BOARD OF HEALTH' TAG NO. 0 ]C IC IC ]C ] DATE 0 -4�(;
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIN CA D