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TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION tf
MAP NO. PARCEL �,NOO. 6C- Z-
ADDRESS OF TANK: VILLAGE: /4-14 A/f- cS
MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) : ` f �
OWNER NAME: XC-.1'tq-1n6A,1) C/-let(- 5 PHONE. ��� ��u ' r� /Z �
INSTALLATION DATE: BY:
INSTALLER ADDRESS: -CERT.140.
*TANK LOCATION: lf-f',llk /-!`t�l f r1f h`r 1 /�)'1144 •jXAI
(O C S CR I U C TANK L O C AY 2 ON W 2 TH R R C P U C T TO m U I L O 2 N O
CAPACITY 2�0 TYPE OF TANK ? AGE `� YRS. FUEL/CHEMICAL 2- rt4C t-
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TESTING CERTIFICATION [ ] PASS C ] FAIL DATE
LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION [ ] YES C ] NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED C k] YES [ ] NO DATE`
CONSERVATION [ ] CHECK IF N/A DATE
BOARD. OF HEALTH TAG NO. C f .`� ] DATE
PLEASE PROVIDE A SKETCH SHOWING THE .TANK. LOCATION ON THE BACK OF THIS CARD
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