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APPL!GATION FOR PERMIT
Yarmouth
01/3r/20L4
ln accordance \Mith the provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
by
Address: 33 Aunt Janes Rd /South Yarmouth, MA 02664
For permission to: Above Ground Tank Removal 527CfiR 9.02
Name of Competent Operator:Tank Removal Services
Date lssued-Rejecled o7 / 3L / 2Or4 By
Date of Expiration: oB /3L/20a4 Fee: $ s 0 ' 00 $ Paid
Cert. No
prlicant)
137
AUNTO3
(Signature of a
Due
City or Town:
Date:
PgrmllltlumSgy' 101514
Make application to local fire department.
Fire department retains original application and issues duplicate as permit.A
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APPLICATION and PERMIT
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Fee
for steel underground storage lank removal and transportation to approved tank disposal yard in accordance
with the provisions of M.G.L. Chapler 148, Section 38A, 527 CMR 9.00, application is hereby made by:
Atter removal(s) ('consumptive use" fuel oil tanks mpted) send Form FP2 r Form FP-290R signed by the local flre department to
MassDEP, Bureau of Waste Preventjon UST Prog
'lntemational Fire Code lnstitute
SiqnaIure (il applyino Io.
Cily ztp
Tank Owner Name (please print)
Addres
ruu,"-l--] fl-S- t -L- 1
Df lFCl' Certified
w\.-
Other
Company
Signature (if applying for permit)
Address
Olher _ED lFCl' Certified D+ LSP #
Co. or lndividual
Signature (if applying lor permit)
Address
Substance Last Stored
5
I
I
c.7-t , V,L 1n Ao
Tank Capacity (gallons)
Tank Location
State Lic. #Firm Transporting waste A.{3367 eot@
Tank Yard #Approved Tank Disposal Yard
t8 R-J E -dType of lnert Gas_Tank Yard Address
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)-i t- 17
Vr,*- ct-z
Dig Safe approval number:
FDID#
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D! Sale TollF€e Iel. Nurbe. - 80G
Signature / Title ot Officer granting pe
City or Town
Date oI lssue Date ol Expiration
Trenching Permit #
Permit# /O I S/L/
ram,PO Box 120-0165, Boston, MA 02112-0165
Tank Owner
Removal Contractor Contamination Assessment
O'-*----:
Tank lnformation
Hemarks:
Tank Dimensions (diameler x length)
Disposal lnformation
\-l 7
/Hazardous Waste Manilestf E.P.A. # _
Approvals
FP-292 (revised 3/10)