5 ALBION UST REMOVAL De.,��:tq�eKt°� 3� Se��ced ice °� tie State 3���2'ar�l:aB
RECEIPT OF DISPOSAL OF UNDERGROUND STEEL STORAGE TANK
Form FP 291
r' 5mpg tRILtl--P1w��►�
NAME AND ADDRESS OF APPROVED TANK YARD AAC �AAenwrn��w �+T_
�fw V V�� MEO RICIAL v■e
905
APPROVED TANK YARD NO. Tank Yard Ledger 502 CMR 3.03(4)Number: 4
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 rP-rovis for proving Und ound Steel Storage Tank dismantling yards. A valid permit was issued by LOCAL Head of Fire Department.
FDID# (�/) to transport this tank to this yard.
Name and itle f approved tank yard owner or ow7horize repr t
�40 L
SIG-NATURE 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 / , ,�
Wle5 � J
(No.and Street)
Previous Contents
i
Diameter Length (City or Town)
Date Received i Ul
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.
Make application to local Fire Department. '
Fire Department retains original application and issues duplicate as Permit.
p
0
r
APPLICATION and PERMIT Fee: $30.0=
for storage tank removal and transportation to approved tank disposa[yard In accordance with the provisions
of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by: '
I L t 61g U 1 Y
Tank Owner Name(please print) D'Nalt Family X'
iSignature(if ap rpermd
Address 5 Albion Street Salem, MA 01970
Sweet City :i state Zip
Company Name H & S Tank Cleaning, Inc. Co.of Individual
Print Print
Address 101R Foster St. Peabody. MA 01960 .Address
(978)531-6433 Print ""'
Signature(if applying for permit) Signature(If applying for permit)
❑ IFCI Certified Other ❑ IFCI Certified ❑ LSP# Other
-Dank Location 5 ALBION STREET _ - SALEM
Steer address city
Tank Capacity(gallons) (1) 275 gallon above groLnd Substance Last.Stored #2 fuel oil
Tank Dimensions(diameter x length)
Remarks: Tank removal scheduled for(1%1`2/0-1-11
Firm transporting waste H & S Tank Cleaning, Inc. State Lic. # MA326
Hazardous waste manifest# NSA E.P.A.# MP9787453346
Approved tank disposal yard Turner Salvage Tank yard# 002
Type.of inert gas N/A Tank yard address 225 Commercial Street Lynn, MA 01905 _
City or Town VSALEM� FDID# 09258 Permit#
Date of issue _ ��2�1J/ Date of expiration
Dig safe approval number: g Safe Toll Free Tel. Number-800-322-4844
Signature/Title of Officer granting permit
Aftor removal(s)send Form FP-29OR signed by Local Fire Dept.to UST Regulatory Compliance Unit,One Ashburton Place,
Room 1310, Boston, MA 02108-1618.
FP-292(revised 9/96)