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TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
C OWNER
AND INSTALLER INFORMATION
ADDRESS: �/a l l I�/ / loe MAP NO. 30q PARCEL NO.
OWNER NAME: MA ! jr-,/)SM),cl VILLAGE: 1 1 ! I /')S
INSTALLATION DATE: BY:
ADDRESS: CERT. NO.
TANK INFORMATION
LOCATION OF TANK: \ C."!�!!`a f\/ �� l G�ll
CAPACITY Or TYPE {_. AGE30 FUEL/CHEMICAL OF-1 . OIL
TESTING CERTIFICATION C I PASS C I FAIL DATE
LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION C I YES C ] NO DATE TO .BE REMOVED
FIRE DEPT. PERMIT ISSUED C ] YES C ] NO DATE
CONSERVATION Cx] CHECK IF N/A DATE
BOARD OF HEALTH TAG. NO. C ]C ]C ]C 31 ] DATE /0 �-Af'� � Vc to
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PLEASE PROVIDE. A SKETCH SHOWING THE, :TANK LOCATION ON THE BACK OF THIS CARD
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