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HomeMy WebLinkAbout0126 LINCOLN ROAD - Health 126 Lincoln Road Hyannis f' A= 270-056 v Commonwedth of Massachusetts .John Grad Executive Office of Environmental Affairs D.E.P. Title V Septic Inspector Department of P 9 Environmental Protection � os) s6,4-6 _ 40 f Rue1w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO R8 2 .5 1997 PART A CERTIFICATION Property Address: 126 Lincoln Rd. Hyannis Address of Owner: Date of Inspection:4121197 (If different) Name of Inspector:JohnGracl Mortgage Funding Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes This inspection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is performing at the time of the Inspection.My inspection does _ Needibmflit rther E aluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the X Fails septic system and any of Its components useful life. Inspector's Signature: Date: 4121197 The System Inspector shall s a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: P 1/7 -7 Check A, B,C,or D: ® s- (� A] SYSTEM PASSES: ©��1 �-7 _1 have not found any information which indicates that the system violates any of the failure criteria f� defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.) The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 126 Lincoln Rd.Hyannis Owner: Mortgage Funding Date of Inspection:4121197 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The,system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. x SAS is in hydraulic failure. (revised 11/15195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 126 Lincoln Rd.Hyannis Owner: Mortgage Funding Date of Inspection:4►21197 D) SYSTEM FAILS(continued) Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6°below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11115195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 126 Lincoln Rd.Hyannis Owner: Mortgage Funding Date of Inspection:4121197 Check if the following have been done: x Pumping information was requested of the owner,occupant,and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. nlaAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 126 Lincoln Rd.Hyannis Owner: Mortgage Funding Date of Inspection:4121197 FLOW CONDITIONS RESIDENTIAL: Design flow: 0 gallons Number of bedrooms: 2 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): No Seasonal use(yes or no): No Water meter readings,if available: nla Last date of occupancy: 4 months ago COMMERCIAL/INDUSTRIAL: Type of establishment: Wa Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n1a Last date of occupancy: n1a OTHER: (Describe) n1a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last year. System pumped as part of inspection: (yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: n1a TYPE OF SYSTEM Septic tank/distribution box/soil absorptions system X Single cesspool X Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: Approximately 1960's Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 126 Lincoln Rd.Hyannis Owner: Mortgage Funding Date of Inspection:4121197 SEPTIC TANK: (locate on site plan) Depth below grade: n1a Material of construction:X concreate_metal_FRP_other(explain) Dimensions: n1a Sludge depth:n1a Distance from top of sludge to bottom of outlet tee or baffle: n1a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance form bottom of scum to bottom of outlet tee or baffle: n1a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Na GREASE TRAP: (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) n1a I (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 126 Lincoln Rd.Hyannis Owner: Mortgage Funding Date of Inspection:4121197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n1a Material of construction:_concrete_metal_FRP_other(explain) Dimensions: n1a Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: rda Comments: (condition of inlet tee, condition of alarm and float switches,etc.) n1a DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe. Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) D-box is structurally sound PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) n1a (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 126 Lincoln Rd.Hyannis Owner: Mortgage Funding Date of Inspection:4121197 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible:excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: nla Type: leaching pits,number: nla leaching chambers,number:nfa leaching galleries,number: nra leaching trenches,number,length: nla leaching fields,number,dimensions:nfa overflow cesspool,number:2 block pit Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Cesspools are past the effective depth of leaching.system is in hydraulic failure. CESSPOOLS:X (locate on site plan) Number and configuration: one Depth-top of liquid to inlet invert: empty Depth of solids layer: nfa Depth of scum layer: nfa Dimensions of cesspool: TW Materials of construction: block Indication of groundwater: nfa inflow(cesspool must be pumped as part of inspection) nfa Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Cesspool has been full.System is in hydraulic failure. PRIVY:_ (locate on site plan) Materials of construction: nla Dimensions: nfa Depth of solids: nla Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) nla (revised 11115195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'SYSTEM INFORMATION(continued) Property Address: 126 Lincoln Rd.Hyannis Owner: Mortgage Funding Date of Inspection;4121197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' C � k C A 0 � DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS MAPS AND CHARTS (revised 11115195) 9 TOWN OF BARNSTABLE l SEWAGE # LOCATION �� �-•"'c o n �='M` VILLAGE ASSESSOR'S MAP &LOT 70 OSG INSTALLER'S NAME&PHONE N0. SEPTIC TANK CAPACITY N : ✓(.T t -o 0 S (size) oZX II X LEACHING FACILITY: (type) —F NO.OF BEDROOMS a BUILDER OR OWNER PERMITDATE: S" (� -9,7 COMPLIANCE DATE: 9 � Separation Distance Between the: ;Feet Maximum..Adjusted Groundwater Table and Bottom of Leaching Facility private Water Supply Well and Leaching Facility (If any wells exist :Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist ::Feet within 300 feet of leaching facility) Furnishe&by d i TOWN OF BARNSTABLE LOCATION SEWAGE# �— y VILLAGE ASSESSOR'S MAP &LOT,? 76 —oj-6 INSTALLER'S NAME&PHONE NO.iay�c- SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 5 BUILDER OR OWNER ►y b b�ors"—S PERMTTDATE: ��? COMPLIANCE DATE: 9 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet { Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching-facility) Feet Furnished by F �� � I r x fi a ' > �� �. �� -- -- - _. / 1 � 0— ® � Fee No. .�� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for 33i!5poml *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.1 o�fa �;N `GN lw sowner's Name,Address and Tel.No. 0 Assessor's Map/Parcel cy NS Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms a Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow er gallons per day. Calculated daily flow 3 %0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1600 !!!7 A-I y N Type of S.A.S...3'wlLi t-`T4,cvc,2 5 Description of Soil q f � Nature of Repairs or Alterations(Answer when applicable) TV--5-V4k< J's QQ /✓— N caY� �G47 Y pf NGrp.T✓�c�iG�S _Lj JV/y 5 QZ_f 7 /0/ G Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the nvironmental Code and nopto place the system in operation until a Certifi- cate of Compliance has been issued by this lth. ned Date 57 l F Application Approved by Date 7 Application Disapproved for the following reasons Permit No. Date Issued l It � •`r• '- - -.. ..Y ., -w-zr- .. r_r':. ..-�N..-'.• :^ -'r � .• '-.`'r- ^i _fir.. - �. .T e�A -� ' . No. '. .= .sa Fee "°'�r: THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1 Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS N: Application for Mi5p0al *p5tem Con15truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Address or Lot No. ��t N Gp, ��,(C,,, .?wner's Name,Address and Tel.No. Assessor's Map/Parcel 1 kU'T�V%NS e�-�0-a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �o�st abG 65 Type of Building: Dwelling No.of Bedrooms C1;Z Lot Size .�;1 sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow C-)3 0 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank I '�QQ A= rj.4z Type of S.A.S. =' r, rt-T4,u-t&(2 S Description of Soil i4e-,G q KO f � Nature of Repairs or Alterations(Answer when applicable) -r- r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the F J,nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this BodEf of Health. ne Date Application Approved by 4 -Date Application Disapproved for the ollowing reasons Permit No. 9 '7 la Date Issued f ----�----------- ------------------- —————THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( ) Upgraded Abandoned( )by o . -�- at t s has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 1 dated P? - 2 2 Installer Designer The issuance of this perrru�of be construed as a guarantee that the system will function as designed.� .t Date K -- / -- 4 7 Inspector I,'"s, No. Fee THE COMMONWEALTH OF MASSACHUSETTS ! PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miqu al *p6tem Construction Permit Permission is hereby granted to Construct( )Repair( pgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: - I _ 7 Approved by y NOTICE: This Form is to I)e used for the Repair of railed Septic-Systems Only _ t CERTIFICATION OF SKETCII ANU APPLICATION FOR A DISPOSAL NVORKS CONS'I'R GUION PEItMI'l, (WITIIOUT DESIGNED PLANS) { i % 5 , hereby certify that the application for disposal works construction permit signed by me dated M/--5 7 , concerning the property located at /a`0 L%w"d l"., y meets all of the following criteria: There are no wetlands within 300 feet of the proposed septic system t/. There are no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leaching facility �/ • There is no increase in flow and/or change in use proposed / There are no variances requested or needed. SIGNED: DATE: `Iy` 7 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. jxcrt � . {. ,� ,� .. �- 4 � p i V-1­ TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: Gr '4 5 3EA\j1y_r S Mail To: BUSINESS LOCATION: 17-to riL6t-7-( A'o A-10- T41S III 02.(6t Board of Health Town of Barnstable MAILING ADDRESS: 5VN"F- P.O. Box 534 TELEPHONE NUMBER: (�ga f) ?9t, - 5-& Hyannis, MA 02601 CONTACT PERSON: ,N—R EMERGENCY CONTACTTELEPHONE NUMBER: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities tota lAi , at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO � _ This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that yob. ,sto�� Quantity ., Case Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) (y Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) 2— Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes _ Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) 7-- Paint & lacquer thinners PCB's Z Paint & varnish removers, deglossers Other chlorinated hydrocarbons, C Paint brush cleaners (inc. carbon tetrachloride) � Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy- Health Department/ Canary Copy-Business IR;v�S,r.-+r-•l,w..^s..,-..ti.•+y}.•,F4-�-,a• .,-_.�;. -_.v.,:.7.,r.: j': � • �+c....� .y. `;� :- k - - . - .. , .. F . � i'...,.•rv.r�-..,n— d}:.n:.} �r,..r'••,,fr'�+�"`'"^"• .p irr- �,hu-,�,: �.r -w...ti,.•..ti.•�»:i.+:.�`l`"""'•-. TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: 6AR ' Pr"N lri1 59C;, Mail To: BUSINESS LOCATION: _f 7-Co �_)T-)LbL-r( AO A-10) N tS i-1w Board of Health Town of Barnstable MAILING ADDRESS: P.O. Box 534 °TELEPHONE NUMBER: (,Co F3 Hyannis, MA 02601 CONTACT PERSON: tin EMERGENCY CONTACTTELEPHONE NUMBER: Does your firm store�any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities"totall , at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that yostore: 0 /Tt LO o[S Qua t+tyl�ase_..,. _( .uaRW/Case y Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants y Motor oils/waste oils Road Salt (Halite) �- y Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) .,2-. Wood preservatives (creosote) Rustproofers Swimming pool chlorine )_ Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, ( Paint brush cleaners ,�' (inc. carbon tetrachloride) 2•, Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may ; Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) - 1 Other cleaning solvents - 1 Bug:and.tar,rem overs .„ -a�-'','• -r- " "'-• .` - ,r '�` .'- Household cleansers, oven cleaners WhitelCopy- Health Department/ Canary Copy-Business