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TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION 19
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INSTALLATION DATE: BY:
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LOCATION OF TANK 1 Va r 8A ( _ -r6l,fj`~
CAPACITY �� TYPE 0 -t r AGE . !'aFUEL/CHEMICAL t.
TESTING CERTIF TION C ] PASS C I FAIL DATE
. ; LEAK DETECTION C I CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION C I YES ] NO DATE TO BE REMOVED IV2
-FIRE DEPT. PERMIT ISSUED C ] YES C ] NO DATE
" jCUNSERVAiION C 7 CHECK IF N/A DATE
;BOARD OF HEALTH TAG NO. ]C ]C ]C ] DATE
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
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TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
mi /�O�WNER AND INS.T�/ALLER INFORMATION
ADDRESS• t `�"� �1 MAP NO. PARCEL NO. [
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OWNER NAME: CFIFL.1 A a V VILLAGE: r ���ANTS"
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INSTALLATION DATE: BY:
ADDRESS: CERT. NO.
ppo J 6 1� 3 `1 TANK INFORMATION
LOCATION OF TANK: A/,,'-R i
CAPACITY 0 00 TYPE 4f66 1.+ ____ AGE FUEL/CHEMICAL
TESTING CERTIFICATION C I PASS C ] FAIL DATE
LEAK DETECTION ] CHECK IF N/A TYPE/BRAND (�
.ZONE OF CONTRIBUTION C ] YES C 7 NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED C ] YES 1/7 NO DATE 1
CONSERVATION C ] CHECK IF N/A DATE
BOARD OF HEALTH TAG NO.6 E 14 ]C ]C 1[ ] DATE Z oll,
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD