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TOWN OF BARNSTABLE
UNDERGROUND FUEL AND CHEMICAL STORAGE SYS MS
ASSESSORS MAP N0. /U PARCEL NO. O
ADDRESS, _ � VILLAGE 14 A/wis
NAME a
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CONTACT PE ON PHONE NUMBER
LOCATION OF TANKS: CAPACITY: .TYPE OF FUEL AGE: TYPE: LEAK
OR CHEMICAL: ® DETECTION
.( 6 12 'fI - SYSTEM'
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77
DATE OF PURCHASE OF. EACH: 1. 16� 2. 3. 4. 5. _
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD.