UST removal REcord RECEIPT OF DISPOSAL OF UNDERGROUND STEEL STORAGE TANK
Form FP 291
NAME AND ADDRESS OF APPROVED TANK YARD urner I rucking &SavageCo—.-,Tnc. .
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APPROVED TANK YARD NO. 0 V Tank Yard Ledger 502 CMR 3.03(4)Number:
I certify under penalty of law I have personally examined the underground steel storage tank delivered to this"approved tank yard"by firm,corporation or
partnership -and accepted same in conformance with Massachusetts Fire Prevention Regulation 502
CMR 3.00 ProvisionsfgrApprqApg U rground Steel Storage Tank dismantling yards. A valid permit was issued by LOCAL Head of Fire Department.
FDID# to transport this tank to this yard.
Nam nd cia Me of approv d tank yard owner or owners authorized representative:
TITLE DATE SIGNED
This signed receipt of disposal must be returned to the local head of the fire department'FDID# pursuant to 502 CMR 3.00.
EACH TANK MUST HAVE A RECEIPT OF DISPOSAL
TANK DATA — TANK REMOVED FROM
Gallons Z-C- E
(No.and Street)
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Diameter Length ( sty or Town)
Date Received
Fire Department Permit#
Serial#(if available)
Tank I.D.#(Form FP-290)
Owner/Operator to mail revised copy of Notification Form(FP290, or FP290R) to : UST Compliance,
Office of the State Fire Marshal, P.O. Box 1025 State Road, Stow, MA 01775.