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HomeMy WebLinkAbout0105 PIN OAKS DRIVE - Health 05 Ping Oaks Drive N Barnstable P 279 067 71 r u J j� R • b r � r o COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF E NVIROrtMENTAL AFFAIRS ` DEPARTMENT OF ENVIRONMENTAL PROTECTION iOAP LOT TITLE S OFFICIAL INSPECTION FORM - SUBSURFACE SEWAGE DISPOSAL VOLUNTARY OAS PART A CERTIFICATION Property Address: 0 RECEIVED Owner's Name: e e p 2004 owner's Address: AUG 3 Date of Inspection: .TOWN OF BARNSTABLE HEALTH DEPT. Name of Inspector. lease print) Company Name• Mailing Address: Telephone Number:. _ _ - 07-(00 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance ti on site sewage disposal approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000 . etem d am a DEP system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: d t 0 The system inspector-shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving . authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that times This inspection does not address flow the system will erfor conditions of use. P m in the future under the same or different Title S Inspection Form 6/15)2000 page l INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS OFFICIAL INS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �s �— owner. Date of Inspection: Inspection Summary: Check AAC,D or E/ WAY complete all of section D A, System Passes: I have not found any information which indicates that any of the fat7ure criteria described in 310 CINR CMR 15.304 exist.Any failure criteria not evaluated are indicated below. 15 303 or in 310 =' ;J. x {' Comments: , a System Conditionally Passes: components as described in the"Conditional Pass"section need to be replaced or One or more system lm , roved the Board of Health,will . repaire . e system,upon completion of the replacement or repair,as approved by t determined(YAND)in the for the following statements.If"not d ined"please Answer yes,no or . explain. The septic tank ism and over 20 years old*or the septic tank(whet h etal or not)is structurally unsound,exhibits substantial in 'on or ex5ltration or tank failure is im ent.System will pass inspection if the tic tank as approved by oard of Health. existing tank is replaced with a co �ng Sep it soon t leaking and if a Certificate of Compliance 'A metal septic tank will pass inspect, if it is structure y indicating that the tank is less than 20 ye old is available. ND explain: observation of sewage backup or break or static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled uneven d ution box.System will pass inspection if(with- approval of Board of Health): b en pipe(s)are replaced bstruction is removed distribution box is leveled or reply ND explain: . r ired pumping more than 4 times a year due to broken or obs ted pipe(s).The system will The system p inspection if ith approval of the Board of Health): ass broken pipe(s)are replaced obstruction is removed ND explain: 2 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART A Ts CERTIFICATION(continued) Property Address: Owner. 2 Date of inspection: ' Further Evaluation is Required by the Board of Health: itions exist which require further evaluation by the Board of Health in order to determine if th is failing to test public heahh,safety or the environment. e 1- System w Pass unless Board of Health determines in accordance with 310 CMR 15.3 system is no auctioning in a manner which will protect b)that the public health,sate and the safety vironment: F _ Cesspool or p 'vy is within SO feet of a surface water _ Cesspool or pri 's within SO feet of a bordering vegetated wetland or a salt arch 2. System will fail unless the Board o eaith(and Public Water S pijer,itany)determine system is functioning in a manner that pr ects the public health, fety and environment: s that the _ The rystem has a septic tank and soil ab rption system AS)and the SAS is within 100 feet of surface water supply or tributary to a surface w supply The system has a septic tank and SAS and the is within a Zone 1 of a public water supply. The system has a septic tank and SAS and.th AS , within SO feet of a private water supply well, The systemhas a septic tank and SAS Private waterter supply well**. the SAS is le han 100 feet but 50 feet or more from a supply Method used determine distance "This system passes if the well water alysis,performed at a DEP ified laboratory, for bacteria and volatile organic compo ds indicates that the well is free pollution from thaat facility and the presence of ammonia nitrogen d nitrate nitrogen is equal to or less t S failure criteria are triggered.A py of the analysis must be attached to this ppm'provided that no other Other. 3 t page 4 of l I OFFICIAL INS PECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: . 0 owner. Date of Inspection:'. D. System Failure Criteria applicable to all systems: You must indicate-yes-or-nor to each of the following for a!1 inspections: Yes No a into facility or system component due to overloaded or clogged SAS or cesspool Backup of sewage and or surface waters due to an overloaded or Discharge or ponding of effluent to the surface of the ground clogged SAS or cesspool ed SAS or v,o Static liquid level in the distribution box above outlet invert due to an overloaded or clogg cesspool 6"below invert or available volume is less than'A day ow 1-iquid depth in c�P°O1 is less than NOT due to clogged or obstructed pipe(s).Number )� � Required pump dg more than 4 times in the last year__ Of times pumped privy 1 or is below high ground water elevation. ho Any portion of the SAS,cesspoo Y`d Any portion of a surface water supply or tributary to a surface of cesspool or privy is within 100 feet water supply- is within a Zone 1 of a public well. m o Any portion of a cesspool or privy Any portion of a cesspool or Privy is within 50 feet of a private �5�feet from a private water Any portion of a cesspool or privy is less than 100 feet but greater o supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds onia indicates that the well is free from pollution from that facility and he hat no other fae of ilure criteria nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided are triggered.A copy of the analysis must be attached to this form-1 ore of the above failure criteria exist as (Yes/No)The system fails.I have determine the em faine or ls.The system owner should contact the Board of described in 310 CMR 1530 , to correct the failure. Health to determine what.will be necessary S Large ystems: a design To b onsidered a large system the system must serve a facility with slow of 10,000 gpd to 1 0 gPd- either es"or"no"to each of the following: You must in t "Y (The following trite ' I to large systems in addition to the criteria above) yes no _ the system is within 400 f a surface drinking wa PPIy the system is within 200 feet of a tribu a surface drinking water supply stem is located in a n' en sensitive area(Int Wellhead Protection Area-IWPA)or a mapped — he sY 1 Zone II of a public supply well If you have answere es"to any question in Section E the system is consider significant stem threat,ons dered aered "yes"in Sectio above the large system has failed.The owner or operator of any l • si ifican at under Section E or failed under Section D show; grade the system in acc office of the Department. ce with 310 CMR gn 15.3 . e system owner should contact the appropriate gr 4 Page 5 of I 1 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ' CHECKLIST Property Address: Owner: ' Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the followine: Yes No — Pumping information was provided by the owner,occupant,or Board of Health Were an of the system components pumped out in the us two weeks? T 1� Y Y� � P Pe Pn�o _ 11 D Has the system received normal flows in the previous two week period? _ LIM Have large volumes of water been introduced to the system recently or as part of this inspection? U6 Were as built plans of the system obtained and examined?(If they were not available note as N/A) 'u— — _ Was the facility or dwelling inspected for signs of sewage back up? — Was the site inspected for signs of break out? — Were all system components,excluding the SAS,located on site? n w _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition cif the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? V _ Was the facility owner(and occupants if different from owner)provided with information on the proper thaintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no — Existing information.For example,a plan at the Board of Health _ Determined in the field(if any of the failure_ criteria related to Part C is at issue approximation of distance unacceptable)[310 CMR 15.302(3)(b)J OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 e Owner. ti Date of inspection: FLOW CONDITIONS RESIDENTIAL )l Number of bedrooms(design): Number Number of bedrooms(actual DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x if of bedrooms)--L ill D Number of current residents: 2 Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):W[if yes separate inspection required] Laundry system inspected(yes or no):JID Seasonal use:(yes or no):U6A Water meter readings,if a ilable(last 2 years usage(gpd)): 1_ Sump pump(yes or no): T'u Last date of occupancy: GQMMERCIAJANDUSTRIAL Type ishment• Design flow(b 310 CMR 15203): tDd Basis of design flow(sea ons/sgft,etc.): . Grease trap present(yes or no):_ Industrial waste holding tank pre s o):_ Non-sanitary waste di to the Title 5 sys es or no):_ Water meter ' gs,if available: Last of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: v,e5` Was system pumped as part of the inspection(yes or no):�p If yes,volume pumped: Ilons--How was quantt pu ped determine ? Reason for pumping: �tlVl ey,' Y`c G„)a - - S A O Grcj -prop" p t 4 TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool . _ivy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Irmovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the D1EP approval I IOther(describe): S3 C n�%ne cl k0 d df�' P t +S_ earl e4c d X g Approximate age of all components,4ate installed(if known)and source of information: TT Were sewage odors detected when arriving at the site(yes or no): 6 ' Page 7 of 11 OFFICIAL INSPECTION FORM NOSAL SUBSURFACE SEWAGE P SYSTEM INSEC110N FFOR ASSESSMENTS PART C INFORMATION(continued) O SYSTEM INF . Property Address: Owner.or Date of laspectio8: BUILDING SEWER(locate on site plan) Ic l r Depth below glade: l Materials of construction: cast iron 40 PVC_other(explain): n .t•�X) Distance from private water supply well or suction line: Comments(on condition of joints,ven' evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Co(WVA C� 1 • Depth below grade:� 1 eth lene Material of construction: concrete_metal fiberglass _ _other(explain) p co If tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no): attach a copy of (_ certificate) K �t Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: —] Scum thickness:,fie I I Distance from top of scum to top of outlet tee or baffle: 1 rr Distance from bottom of scum to bottom of outlet tee oj bafll : I How were dimensions determined: r00e q Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,ev' ence of leakage,etc.); E' - >cGQ. CEASE TRAP: (locate on site plan) Depth below Material of constructio . concrete metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee a Distance from bottom of scum to botto outlet tee or ba Date of last pumping: Comments(on pumping re endations,inlet and outlet tee or baffle condition,s t integrity,liquid levels as related to outlet in idence of leakage,etc.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I br. Owner. Date of Inspection• SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. y A /AIle 2 � I i 10 r Page 11 Of 11 r OR _ OFFICIAL INSPECTION FORM—NOT SYSTEM INSPE ASSESSMENTSAY CTION FORM SUBSURFACE SEWAGE DISPOSAL A� C SYSTEM INFORMATION(continued) Property Address• OS p Owner. AW Date of Inspection- SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 1Skfeet " Please indicate(check)all methods used to determine the high ground water elevation:. Obtained from system design pions on record-If checked,date of design plan reviewed: observed site(abutting property/observation hole within 15o feet of SAS) Health-explain: local Board of Health-e Checked with ers- attach documentation) install (Checked with local excavators, A �0 i Accessed USGS database-explain: how ou established the igh round wa er elevation- r, Yo must descrtke y 6 ID io s tt I �� ! �i \ /I V �..� / .c,t. ii �.-""----" I _' ` —----- - I © v f � II `. y l/ <� NOV 20 '97 12:06 BARNSTABLE FIRE DEPT P.1 f, BARNSTABLE FIRE DEPARTMENT 3249 Main Street—Y.U.Box 94 o% Barnstable,Massachusetts 02630 508-362-3312 u FAX: 508-362-8444 WILLIAM A.JONtS,III GLENN B.COFFIN,CAPTAIN FIRE CHIEF FIRE PREVENTION RNovember 20, 1997 MFRGROUND TANK REMOVAL W FICATION; The 6,000 gallon underground fuel storage tank located at: 105 Pin-Oaks Drive Has been removed on this date and transported to an approved Massachusetts Tank Disposal Yard. Upon examination of the excavation there was no evidence of leaking product. The tank was in -aii(TSR�o visible leaks in the bottom of the tank. The tank was ordered remove d cavoion backfilled. enn C fain ,�sessbr'!f offioe (1st floor);. c `TN¢T Assessor's map and lot number .... ..l.l.....:.. ! ..:... s Sys ANUST ��� Board of Health (3rd floor): n ���® �� CO�rP �9 �V C L!A Sewage Permit number ....(.�1 .........�............................. WITH TrrLE 5 E9E39TAXLE, J==@�i�.�:c� .1 MADL Engineering Department (3rd floor): f Y DNME 1639• e� g ..��}�.......:...�...�� �- ,' I�DTAL CODE A . House number ..:_............................ . . ... TOWN REGU APPLICATIONS PROCESSED 8:30-9:30 .A.M, and: 1:00 2:00 P.M.Q only TOWN OF -• AR NSTABLE BUILDING I . SPECTOR -n�� ;P- _ APPLICATION FOR PERMIT TO M.U. t••. •• TYPE OF CONSTRUCTION ....�liza.Jx)lp 1. ..................._..... , .............:........................................... .........................19.8 ' TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to`the following information: Location Ids..... �nJ l� .........���•. ............. t�:L,�:��-�e ..................... ProposedUse ........✓..1. .�. -..... :1a..a�.. i.� 1..Yi.<y........................... ...................................................:......... ZoningDistrict' -r.-X.............................:. .......................Fire District' ..:... ........................................... Name of Owner ...4'� .. ... ... ... .�4�'!?d�LL�jAddress ......h�:!U:N„ ,��ll�„� ►"!,�} �19�1C +......E...... Name of Builder . .....Address ....10� .-:&x. '�t;�...... ... .r.V/'f..6 Name of Architect ..... .l.S..:.. ?. ..:... ....Address .. J� 2:12`�..j..:. �.....::: Numberof Rooms .......... �.......(......................................::...Foundation .....,.... ......................... Exterior ... ' vot,Lap.:.............................................._....:.Roofing .......f.!...... Z.....:..........................................,... L T ..:.I n to r i o r .. l�E �.LOU!�`j' bit ... Floors .... ..r.......•.................. ... ........... ......... . ..Plumbin �.. �..... Heating ` .. .... .) ..... . ........................ g Fireplace ....VIL15IAA).b........ ....Approximate Cost ........ 5p,r, r)................. ... ..... ..... Definitive Plan Approved by Planning Board ---------------------------------19________ . Area " ......................... Diagram of Lot and Building with Dimensions Fee ....... e.'..7�...... ................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 404 72 Z R ,� Oxe -�' ' MQKc lcpiication to Iccal Fire De^:Zr'I pm. ;:. Fire Department retains cr J .gins: appiicatior. a�:c iss:�es ,:;,.! rate _s �erm�t. , u APPLICATION and PERMIT FG_: ter storage tank removal anj ,ransporaticn to approver tank disposal yard ;n accordance �:cith the of M.G.L. Chanter 148, Se 'c;icn .,SA, _�; CP�I�i 9.40, ap;,lie2�lon is heresy mane ,,y. i Tank Owner Name(please print) Address I O -' < v7 Q r� suety "NY sure a� fire) I . _ Co.or Individuai envit - Prnr Address Kr Address r �r Sisim-aure;dap ins for erm; l i JJ Signature (it applying fzr permit) IFCi Certified Other I --- D iFCI Certlfiec� ❑ LSP 4 Otr,er I Tank Location I O ►�� r- i �1 $&Vt AdedV lr Tank Capacity(gailcns) (., p(� '"4 Substance Last Stored Tank Dimensions(diamoter x length) j i Remarks: --- - j i I i j Firm transporting evaste 1 J 4Zd- 15,zj!=E State Lic.# a i HazardOu6 waste manifest# E.P.A.# I Approved tank disposal yard _l��i Y� Ci ��. ��,?� Tank yard# O.-7 Tyre of inert gas IJ.IZrxiF, Tank yard address 777 Dom` . . City or Town Rq fPermmit# r Date of issue Oate of expiration Dig safe approval number trig Safe Toll Free el. N or•800-322-4844, Signature 17do of officer Granting permit - - vu After removal(s)send Form FP.290R signed by Local Fire Dept,to T Regulatory Compliance Unit, One Ashburton Place, Doom 1310,Gaston,MA 021CS-161S. r�� I I t�`•i� FP-292(revised SM) ... ';-=I p-r 7F ,ri.SA� :ER��'� .7D 7^E.�� �TOAAGE 'Ah..:r NA f AND 4--CRESS OF AFPReVED TAUR YAR- APFRDVED :.,NK YAFZ NO. T-^k and :.edger 50Z CMF. 1 cnrt-Ify outer PUI&ity Uf law I have Personally exari.ned the urdergrouid steel stnraoe tonic del_veLed ttuS -approved tank yam" LY f i=, .00rperation or �-artnersh-ip -' �� ��k'/1) and acce •Erred wane in mntormarre vizh w�asa��i,setts r(re� Rreverticr Rvyuldtiun 502 OV 3.00 e-r4risions for AFpenvi.ng lt�der7rrurr3 Steel Storaoe disrantle iiv ors_ A valid pp-cut vas issued by LOCAL Head of Fire �artnnrt FoiD/ / %'_ tc transFort this tank tD th19 yard. . Naft AFII official title of appravW tank yard ovr*r or arners a;;tlorized'represe eve: SIQNAIIM TIME DATE s3a u "his signed T of disposal rust tr return th ed to the local head of e f aro do �a�zt" "'m —— 1. pursi.anc a 5t 1 I.00. IFACH voac KIT,, rAVE A REt�:PT Cr DLcWCI;T.L.) FpR1t F.P. _91 (rev. 11i95) (OVER) Wank Data Tank Removed From: Gallons No. and Street ) Previous Contents 1 -� Y- ( City or Town ) Diameter_ O LE-ggtll-- V-- Date Received �� /'�" Fire Dept. Permit #_ Serial # (if Tank I.D. # (Foml FP-290) Owner/Operator to mail revised copy of Notification Form(H-290, or Fp- 290R) to: UST Compliance, Office of the State Fire Marshal, 1010 Commonwealth Avenue, Boston, Ma. 02215. r- ENVIRO SAFE November-20, 1997 Mt. Anthony Orlandello 33 VVildwood Drive Lvnnfield, MA 01940 RE: Certij7cute of Underground Stora-e Tank Renwvai 105 Pin Oaks Drive Barnstable pillage, MA Dear .Mr. Orlandello. This letter serves to notify you that on November 20, 1997, Env iro-Safe Corporation of Sagamore Beach. Massachusetts (Enviro-Safe) excavated. cleaned and disposed of a 6000 gallon underground heating oil storage tank (UST) located at 105 Pict Oaks Drive, Barnstable V illaue. Massachusetts. A representative of the Barnstable Fire Department was on-site during this tank removal. To the best of Enviro 4afe's knowledge there was no visual or olfactory evidence indicative of a heating oil release in or around the area of the tank excavation. The excavation was then backfilled with clean fill by Enviru-Safe. The tank was cleaned and properly disposed of at Turner Trucking and Salvage Scrap yard (Massachusetts tank yard 002) by Enviro-Safe. If you have any questions regarding these ►natters, please do not hesitate to call tne. Thank you. Heather M. Atwood President Enviro-Safe Corporation H INLVdtnh Please Note New Mailin4 Address: PO Box 810, E. Sandwich, MA 02537 P. O . BOX. 304 SAG BE- AC " A 25 508 ? 8 = 5 - = r. X . = - - ' ' - _ TOWN OF BARNSTABLE LOCATIO SEWAGE # ' VILLAGE ESQ, A SS LOT 21. L L, p INSTALLER'S NAME & PHONE NO- ``,1 SEPTIC TANK CAPACITY G� ` LEACHING FACILITY:(type) 4�j - -1000 GAA. size) AUJI75r NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER .�tti � DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No VETORINO BROS., INC. EXCAVATING CONTRACTORS BARNSTABLE, MASS. 02630 �y Tels• (617) 362-3665 or 362-6354 S 4 Man 1987 Town of Barnstable Board of Health Main Street Hyannis, Bass 02601 5 . To Whom it Concerns; I have inspected the sewage system for Mr. Benn on Pin Oaks Drive and found it to be exactly as shove on the plan. There is three 1000 gal, stonelpacked leach pits aomeated in series. The first one acts as a septic tank and 'Elite others as leach pits. The system is free of solids and in good working order. Nwrfber three pit has yet to have any water in it Any other questions please feel free to call. VOW- Thank y. �,�+!►" '� Thomas F, Vet orino Pres. Vetorino Bros, Inc. Barnstable, Mass. 02630 - f�",,.-... •nr....t'-w.., ...v+..• �y,rr..'i;_,,,,F�Tr,/�•y.:�i•7,�w.d-(-.+`yyA..;l:!'T .4,. iD tee+.rr "n a'^. ,. ..Z .,.. .. .- ten• TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER AND INSTALLER INFORMATION ADDRESS: ff� c ,/ MAP NO. ?PARCEL NO(1/,- 7 OWNER NAME: ° 74,w 1. /0 VILLAGE: INSTALLATION DATE: / BY: ADDRESS: CERT. NO. TANK INFORMATION LOCATION OF TANK: ' CAPAC I TY Ge),, TYPE " AGE " ` FUEL/CHEMICAL TESTING CERTIFICATION C I PASS C ] FAIL DATE LEAK DETECTION Cv'] CHECK IF N/A TYPE/BRAND Z ONE OF CONTRIBUTION C ] YES CA°]°'NO ;6 DATE TO BE REMOVED 4:no / FIRE DEPT. PERMIT ISSUED C ] YES C J NO. DATE CUNSERVA T I ON Cam,�] CHECK''IF N/A DATE BOARD OF HEALTH TAG NO. 7C 3E ]C ]C ] DATE W!I PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF ,THIS CARDS i � `�' �F ® -fi-�-.�--- y F �►' < < - �Q.N W72 4 t• Qp C v v t F , s i= 4� - e �Y 1 r x TOWN OF BARNSTABLE J UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS NAME --rA V L- S A fE!--r:;,A 2A UY�L4 IV ADDRESS O A LS DaZ j UE VILLAGE -SA IZ N S I /E LC LOCATION OF TANK CAPACITY: TYPE OF FUEL AGE: TYPE: OR CHEMICAL NGP--r1f OF: Rovsu- f bcwti tu') (pppp a( 1e 6, ' STE�� (Give same information for any additional tanks on reverse side of card) to DATE OF PURCHASE OF EACH: 1. 2. 3. 4. I DATE OF FIRE DEPARTMENT PERMIT: �q 6 m @- rc-Q21 'ed, ! 0 TESTING CERTIFICATION SUBMITTED: f 06 n PASSED DID NOT PASS n,