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Make application to local fire department.
Fire department retains original application and issues duplicate as permit.
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APPLICATION and PERMIT
Atter removal(s) ("consumptive use' fuel oil tanks exempted) send Form FP-290R signed by local lire dept. to UST Regulatory Compli
ance Unit, Department ol Fire Services, PO. Box 1025, State Road, Stow, MA 01775.
'lnternational Fire Code lnstitute
@Tank Owner Name (please print)Dq;rh qr^/ l-\x
Address B,,6n r. (ir apdyhg ro. p6nrt)
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Company r"rJ, Z'S'
Sfi \^" rl-r--ir..r--Address 6 r-.
HSignature (il a nd for permit)
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Co. or Individual
Signature (if applying for permit)
tr lFCl' Certified D LSP #Other
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Tank Capaciiy (gallons)Substance Last StoredL
Tank Dimensions (diameter x length)
Remarks:
Firm Transporting Waste D. R.<,( ,(UL?state Lic. # Z) 7-
Hazardous Waste Manifest# M Pue E.P.A, #
Approved Tank Disposal Yard \Ai D.J6( Zro.^. \Tank Yard #Wr>/uL \P
Type oi lnert Gas_ Tank Yard Address 'NttD
City or Town FD ID#Permlt#
Date ol Expiration
Trenching Permit #Dig Sale approval number
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Signature / lltle of Otficer granting permit
FP-292 (reused 3rc9)
Fee:
for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chaptell48, Section 38A, 527 CMR 9.00, application is hereby made by:
Removal Contractor Contamination Assessment
Address_p,i,l-_
Tank lnlormation
Disposal Information
Approvals
Date o, lssue _
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APPLICATION FOR PERMIT
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City or Town:
Date:
Yarmouth
02 / 02/2Or2
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
by:
Address: 142 Bayview St /South Yarmouth, MA 02664
For permissaon to: above ground storage tank - removal
Name of Competent Operator:Tank Removal Services
Date lssued-Rejecled 02 / 02 / 2oL2 By
Date of Expiration: 04/02/2012 Fee: $50'00 $Paid
Cert. No.
(Signature oi applicant)
Due
115
142901
permit Number: 100981