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Make application to iucal Fira Depart;7ert.
Fire�eparrmeRt retairns crir•t,ai application and issuas d6plicate as Permit.
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Al and PERMIT
FQr StOray� t nF;relnvov� ,i -lid;,ransportat on to a:�pr9ved tank cisposal yard in ac ,rda.nce-with the provisi%t':S
. a48, �:tion 38A, 5_7 Civt g.GG, application ighereby mac.a 1.,y:
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BAREST r lE Fj'.- DEPT.
INMALS ''
z� Make application to local Fire Department.
Fire Department retains original application and issues duplicate as Permit.
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APPLICATION and PERMIT Fee:
for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by:
Tank Owner Name(please print) Jon Persson X
Signature(i applying for permit
Address 80 Salton Point Rd, Barnstable, MA 02630
Street City State Zip
Enviro—Safe Corporation
Company Name Co.or Individual
Print Print
Address 14B .Jan Sebastian Dr Sandwic Address
Print Print
Signature(if applying for permit) Signature(if applying for permit)
f i IFCI'.Certified Other h IFCI'Certified R LSP# Other
ITankLocation 59 Salton Point Rd , Barnstable , MA
Steet Address City
Tank Capacity(gallons) 2 7 5 A S T Substance Last Stored #2 ;
Tank Dimensions(diameter x length)
Remarks:
7Firm transporting waste Enviro—Safe Corp. State Lic.# 329
Hazardous waste manifest# M AM 8 3 7 2 21 E.P.A.#. MAD 9 8 5 2 6 9 3 2 3
Approved tank disposal yard Turner Inc . Tank yard# 002
Type of inert gas Tank yard address 235 Commercial Street Lynn, MA
Cityor Town 13a ,s a`"g .t. f
'� FDID# Permit#
Date of issue I Date of expiration �F 2-0 f aY
Dig safe approval number: N/A—Abovegroy4d Ta (k Din Safe oll Free Tel.Number_-800-322-4844
Signature/Title of Officer granting permit / / i"
After removal(s)("Consumptive Use"fuel oil tanks exempted)send Form FP-29OR signed by Local Fire Dept.to UST Regulatory
Compliance Unit, Department of Fire Services, P.O.Box 1025, State Road,Stow,MA 01775.
'International Fire Code Institute
FP-292(revised 4/97)
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Barnstable Fire Department .
3249 Main ST
Post Office Box 94
Barnstable, , MA 02630
Permit Certificate - General with Seal
Date: 10/04/2004
Business Name: Correia, Ruth
Address: 80 Salten Point RD
Barnstable, MA 02630
Phone: s
The following permit has been issued:
Permit No. 980382
Type: 01 Removal of tank (s) from property
Issued Date: 10/04/2004
Effective Date: 10/04/2004
Expiration Date:
Notes : For storage tank removel and transportation to approved tank
disposal yard in accordance with the provisions of M. G. L. Chapter
148, Section 38A,. 527 CMR 9. 00 .
It is the business ' s responsibility to ensure that . conditions are in
accordance with applicable State and Local fire regulations .
Please cont ct Barnstable Fire Department for more information.
nspector: Christopher J Olsen Date
10/04/2004 13:55 Dage 1
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RECEIPT OF DISPOSAL OF UNDERGROUND STEEL STORAGE TANK A
Fam FP 291 \..
urnar ho.
NAME AND ADDRESS OF APPROVED TANK YARD 225�;CjgT/pjm erciat t
Lynn, FIFA 1 idea- -
APPROVED TANK YARD NO. ��,
Tank Yard Ledger 502 CMR 3.03(4)Number: / m(�t,'-
I certify under penalty of law I have personally examined the underground steel storage tank delivered to his'approved tank yard'by firm,corporation or
partnership and accepted same in conformance with Massachusetts Fire Prevention Regulation 502
CMR 3.O�O-P}rovisions fop4pprovi�Ura --ground Steel Storage Tank dismantling yards. A valid permit was issued by LOCAL Head of Fire Department.
FDID4 h l�ss!/ ' to transport this tank to this yard.
Name rid pfficial title of oved ri7 yard owner or owners authorized representabve:
/ ,SIGNATURE T;TLE
1,-'� ,� DATE SIGNED
This signed receipt of disposal must be returned to the local head of the fire department FDID#
EACH TANK MUST HAVE A RECEIPT OF DISPOSAL pursuant to 502 CMR 3.00..
TANK DATA TANK REMOVED FROM
J (�; d-Alffir``
Gallows
t (No.and Street)
Previous Contents
Diameter Length (City.or:Town)
Date Received
Fire Department Permit# '
Serial#(if available)
Tank I.D.#(Form FP-290)
Owner/Operator to mail revised copy of Notification Form (FP290, or FP290R) to : UST Compliance,
Office of the State Fire Marshal, P.O: Box 1025 State Road,Stow, MA 01775.
TOWN OF BARNSTABLE AG4
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS G
ASSESS ORS MAP NO. PARCEL NO. '
/ 01
ADDRESS; 'Ol VILLAGE. L-9L : 0 2432 a
CONTACT PERSON PHONE NUMBER -7
LOCATION OF TANKS: . CAPACITY: TYPE- OF- FUEL. AGE: TYPE: LEAK
OR CHEMICALS DETECTION
`Aab Q®® 1 _ ;" S SYSTEM'
Nq,
DATE OF PURCHASE OF EACH: 1. f 2. 3. 4. 5.
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: a . ,. PASSED DID NOT PASS
PLEASE. PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD.
TOWN OF BARNSTABLE VA LV 6- _fA G433
UNDERGROUND FUEL AND .CHEMICAL STORAGE SYSTEMS
ASSESSORS MAP NO. PARCEL NO.
ADDRESS; / 3 VILLAGE;
NAME'
CONTACT PERSON W .At.LCA/ 12 PHONE NUMBS f° f"�,
LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AG TYPE: - LEAK
a / OR CHEMICAL: DETECTION
�-� �-� e •�� ��v IR.I• / / �r - SY S EM
DATE OF PURCHASE OF. EACH: 1. a/11 2. 3. 4. 5.
DATE OF; FIRE DEPARTMENT PERMIT: _9 /„ '
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
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PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. MOLD, G r�
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PERMIT'TO- , INSTALL - ALTER R, g -e- ,
4 } = FUEL OIL,:BURNING EQUIPIVIENT1 k
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in accordance vnath provisions#of Chapter 148 G d
.'thereof ' f � Regulations made under authority
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