HomeMy WebLinkAbout21E Document 1998 - -MdKe application to local t-ire Uepartment.
Fire Department retains original application and issues duplicate as Permit.
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ATION 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:
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Tank Owner Name (please print) / Z-A_ d /r-",fc� co/lecg
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Address d 1a� /i n 0,/�C
/ 51gnature (it aplkwng (or permit)
Street
City State Zip
ICompanyName 661x,�Ae COX t°11
print
Co. or Individual
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Address 3 y % 4 �rdt/tr 57, W/ / ' m'�" �u
Print
Print
Address
Print
Signature (if app for r
Signature (if applying for permit)
P-fFCI Certified . Other
❑ IFCI Certified ❑ LSP # Other
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Tank Location rr �j>`
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Sleet Address
City
Tank Capacity (gallons) /Q) (/0122
Substance Last Stored 02
Tank Dimensions (diameter x length)
Remarks:
Firm transporting wasteL U
State Lic. #�
Hazardous waste manifest#
E.P.A. # AIAii 0 5Yy 9 r
Approved tank disposal yard /0A713Cil e/1 U
Tank yard # 0 0
Type of inert gas Tank yard address _'<O2
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City or Town ec}Gi
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FDID# �- %Uj' Permit#
Date of issue '� ' J — 1�
Date of expira 'on
Dig safe approval number: �fr /
Di a Te%!1 Free Tel. Number - 800-322-4844
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Signature / Title of Officer granting permit
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After removal(s) send Form FP-290R signed by Local Fire Dept. to UST Regulatory Compliance Unit, One Ashburton Place,
Room 1310, Boston, MA 02108-1618.
FP-292 (revised 9/96)