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APPLICATION FOR PERMIT
City or Town:
Date:
permit Number: 100956
ln accordance with the provisions of M.G.L. Chapte l48, as provided in Section 10 A application is hereby made
by:
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For permission to: Above Ground Tank Removal 527CMR 9.02
Name of Competent Operator:Tank Away p: 617-561-1117
Date lssued-Rejecled 0L/ L2/ 2OL2 By
Date of Expiration: 02 /L3/2oL2 Fee: s50 ' 0 0 $ Paid
Cert. No
(Signature of applicant)
Due
Yarmouth
Address: 7 Nottingham Dr /South Yarmouth, MA 02664
THEUOl
NOTTO2
ruaxe apprcauon Io tocat ttre uepartmenl.
, Fire Department retains original application and issues duplicale as Permit.d\
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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, SZ7 CMR 9.00, application is hereby made by:
Atter removal(s) ('Consumptive Use" luel oil tanks mpted) send F .290R slgned by Local Firo DePt. to UST Begulatory
Compliance Unlt, Departmenl of Fire SeMces, P.
'lnt€mational Fire Code lnstltutB.
FP-2S2 (revis6d {t97)
@
I Tant Owner Name (please prinl)
lb$i@ llappti1g to. *nn)t X!E
Zp
Address
o{Tot)
tr rFcr
n
for
t( Au,A
sNnvsHtr,
Olher _E lFCl' Certified tr LSP #_ Other _
Co. or lndividual
Address
Company Name
Signature (if
Addr6ss
Slgnature (if applying tor pemttl
Tank Location
B€rnarks:
Tank Capacity (galloos)47-'
Tank DimBnsions (diameter x length))7xLtL Xb o
clv
rJ
#d otLSubstance Lasl Slored
unxvu,a^oo,"uA?5 Lortll^</? t-AtL {T Y'.lt
Firm transporting waste e,
Tank yard *c)o 0.
TType ol inerl gas
E.P.A. d /hv L)-l ?t/0 BqO
/v n/u/"n s
(06tL\ tL$L State Llc. #
Hazardous waste manllsst#
Approvsd tank disposal yard
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o 5t(
Dig Sale Toll Freo Tel. Number - 800-322-48/4
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Signalure / Tille ol Oflicer granting permll
Dig ssle approval number:
Permit#City or Town
Date ol issue
Box 1025, Stale Road, Stow, MA 01775.
Removal Conlraclor
Al'r
Tank lnlormalion
Disposal lnlormalion
Approvals
Dale of expiralion
RECEIPT OF DISPOSAL OF UNDERGROUND STEEL STORAGE TANK
FORMERLY CONTAINING MOTOR FUEL
NAME AND ADDRESS OF APPROVED TANK YARD:
Lvnn, MA 01905
Approved tank yard no rank yard Ledser 502 cMR 3.03(4) N"*b"r.cllzz:+Lq
I certify under penalty of law I have personally examined the underoround steel storage lank delivered to
this "approved tank yard" by (firm, corporation or partnership)
and accepted same in conformance with Office of the State Fire Marshal Regulations 502 CMR 3.00
Provisions for Approving Undergrou
by the head of the LOCAL fire depa
to transport this tank to this yard
Name and official title of approved tank yard owner or owners authorized representative
Signatxre Ti e Date signed IL
nd Steel Storage Tank Dismantlpg Y!rdL A valid permit was issuedrtmentFDlD# ()14'JI
TA.NK DATA:
Gallons.
Prevlous contents
Diameter:
TANK REMOVED OM:
No. and Slreet
City and Town:
Fire Dept. Permit #
Notes:
'(Y
Length
Date Received
Serial # (if available)
Tank l.D. # fFcrm FP-290)
EACH TANK MUST HAVE A RECEIF'i OF DISPOSAL
Owner/Operator to mail revised copy of Notification Form (FP290, or FP290R) to local fire
department and:
Department of Environmental Protection
Bureau of Waste Prevention - UST Program
PO. Box 120-0165
Boston, MA 02112-0165
This signed receipt of disposal rn(isi be rcturn€d tn lh,) head of the local fire departmen:'
Fo.m FP 291 (Rev. 11/2009)
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