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APPLICATION FOR PERMIT
City or Town:
Date:
Yarmouth
LO /28 /zOtO
permit Number: 100681
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
by:
Address: 64 Adams Rd /South Yarmouth, MA 026O4
For permission to: above ground storage tank - removal
Name of Competent Operator:Tank Removal P: 778-8265
Date lssued-Rejeded LO /28 / 2OLO
Date of Expiration: oL/28 / 20lL
By
Cert. No
Fee: 52s.00 $ paid
(Sagnature of applicant)
Due
't37
ADAM04
Make application to local Fire Department.
Fire Department retains original application and issues duplicate as Permit.s'\%.rr-*r"** ,bt */a//hr*"/*t fu
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APPLICATION and PERMIT Fee 2 ('
lor storage tank removal and transportation to approved tank disposal yard in accordance with the provisions
ol M.G.L. Chapter 148, Section 38A, S27 CMR 9.00, application is hereby made by:
After romoval(s) ("Consumplive Use'fuel oiltanks exemptsd) sand Form FP290F signed by Local Fire Dept. to UST Flegulalory
Compliance Unit, Department ot Fire Services, P.O. Box 102S, State Road, Stow, MA Ojr75.
'lnternational Fire Cods lnstitute
FP-292 (revised 4/97)
Tank Owner Name (pt"u". prino M X
1
Ctty
Address AD S6n,-tta (it.wriag lot !6fin)
t l,D
lFCl'Certified Other
I
A-)
D
Address S
ilor permirl^f+Yol'rgnature (ir
Certified O LSP#- Other
Company Name Co. or lndividual
a\\
ixlen
f-Iu
f\\-VL')^,.\-/1>lTank Location 6,.-t
Tank Capacity (gallons)
Tank Dimensions
Bemarks:
Ada *:6D Dvr \
cry
Substance Last Stored
L11-Stale Lic. S
Hazardous waste manifest#E.P.A. #
Type of inerl gas
Firm transporting
ank yard
Tank yard address
waste A. B "-Y,(vLf
Approved tank digppsal yard t@Ka91_ YDv)
r.r,.^\ MtU(. SF(,r\^z- St*, lzd.srr
HJ @E
Dig Sale Toll Free Tel. Number - aoo-3?2-4844
Permit*
Date of expiralion
FDIDf
Signature / Title of OFficer granting permit
City or Town
Date of issue
Tank Owner
Address
-
Signature (if applying for permlt)
Bemoval Conlractor
S.
>\,
Tanklnbrmation
Dig safe approval number:
.. RETIOVAL SERVICES LLC
58 WILLOW AVE
HYANNIS, MA 02601
508.778.TANK
08/05
JNT
TE
XD
7441
t7017/2110
m3
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$ SC)od
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AIJIHOF]ZED SIGNATUBE
EXPLANATiON AMOUNT
A-r nr..rrna < Sf,:- 7 r7vri ( \,,,\- |IIII
IIII
TO THE OROER OF OESCR'PTION
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Pcrmit *'s: FD
Owncr/Occupant Namc:
(Ciry or Town)
afie C ainlonuultfl of 1r{oss adus et*
Deportmant of p"hti" Sofrty
527 CMR 4.00
Form I
Application for Permit, Permit, and Certificate of completion for rhe Installarion or
to/27,
@arc)
FDID#:q I Fee Paid:
a
6+4m,ns 7
lcl E )tl
[n5rrll4!6q Ad&css:
EJ Hcadng Unit
Bumcr: E New
,J
d exit,ing [.ocation:r'19
Trade Name:
Type:Modcl # or Size:
fr Fucl oil EI Kcroscns E \Vasrc oil
Storage Tank E Nen E Exisring Location:t<n€A.J I
Spcciai requircmcns (or additional safcry dcvices)
E OSv vaivc EI Oit tine protccred E Shcct Rock E] Sprintlcr AFUE: E yes E
Combustion Tesr: Nozzlc Sizc
-
Gross Stack Tcmp.:
New Stack Tcmp.:
Smoke:
CO 3Tcst Brcech Dnfc
no
Tel. * {-aA'4/)-trt-'.
l, the undersigned cenify that rhe installation of fuel buming equipment has been made in accordance with M.G.L. c. 148 and 527 CMR 4.00
currently in effect. Funhermore, this installation has been tested in accordance with such requircments, is now irr proper operating condition and
complete instructions as rc i$ use and rnaintenance have heen fumished to the person for whom the insullation (or alteration) was made.
Co. Name
Addre ss
lnstaller:
5 Qr City:zip:
E€(
Prin! Ndrnr \J VU: T s6"*"@aW
Once signed by the fire depa'qnpnt, this is a PERMIT for the storage and use of oil buming equipment.
lnspected by Date:
Altera on of Fud Oil Burning Equipment and the Storage of Fuer Oil
Scrviced Floor or Unir * i
E Domestic Warcr Hcatcr E Power Vcnr EI Ofier
Mfg:
Locarion:
Type: SrFe t- Capacity: d7 { , ga{s. No. of Tanks:I
Overfire Drafc Efficienry radng 9o:
G'o.-l)olt
A{
I
WHITE COPY: Propertyoyrne/s copy; CANABY CoPY| YF.0.Copy- Retum wheniob i3 completed; Pltlx CoPY.Thi3 copy must be posted at installation.