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TOWN OF BARNSTABLE —' UNDERGROUND FUEL AND CHEMICALoSTORAGE REGISTRATION
� {� � .► / OWNER AND INSTALLER INFORMATION_a ri,
ADDRESS: 2�� a r- r � r n MAP NO. -49 I PARCEL NO.
OWNER NAME: �,1 t,• L e- t�+c . ri�� VILLAGE: tit S
INSTALLATION DATE: BY: '�
ADDRESS: �'• .rat � �• �n�� �� 0. '., - -- _ - ----- ----
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LOCATION OF TANK:
CAPACITY ' TYPE AGE,F, ` FUEL/CHEM I CALF
TESTING CERTIFICAT,rION C.,3..PASS,: v1,4FAI`L . DA;TE Bit
LEAK DETECTION LN3 CHECK IF N%A TYPE/BRAND . �{
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ZONE,y OF CONTRIBUTION)
CI'_ YES C ] NO DATE TO BE REMOVED
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FIRE DEPOT- PERMIT I SSOED C ] YES C ] NO DATE -•r` K
CONSERVATION Cr�t]'CHECK IF N/A DATE s1�,
BOARD OF HEALTH TAG NO. JC ]C ]C ] DATE 1 1�! t✓
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF .THIS CARD
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TOWN OF BARNSTABLE tr, UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
7br—Wo ;OWNER AND INSTALLER INFORMATION
ADDRESS: MAP NO. J 0 —_7.;PARCEL NQr),/ '7
OWNER NAME: /� tia r— a t' a'1*' C� �- �-.� .t .i VILLAGE
INSTALLATION DATE: n BY
ADDRESS: , v, ,.ter t .• rr r,, !, .r CERT.'
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{ TANK INFORMATION.
LOCATION OF TANK: ,
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CAPACITY. c'�3e' TYP AGE, I FUEL/CHEMICAL A`"a e
:TESTING CERTIFICATION hfE I PASS E ] FAIL-, DATE
'LEAK DETEETION Cy] CHECK IF N/A TYPE/BRAND 31i '
ZONE OF CONTRIBUTION C 7� YES C ] NO DATE TO BE REMOVED "
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FIRE DEPT PERMIT ISSUED C 7°AYES C ] NO DATE x.
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LUNSERVA i IbN Ev.1 CHECK F N/A t DATE
BOARD OF HEALTH TAG NO. C %1 3-1 ]C 7 C I DATE d'>
PLEASE"PROVIDE. A SKETCH SHOWING THE TANK LOCATION' ON THE BACK OF THIS CARD
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