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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: Mail To:
BUSINESS LOCATION: ®Voard of Health
own of Barnstable
MAILING ADDRESS: P.O. Box 534
TELEPHONE NUMBER: — Sr 8-0 `f Hyannis, MA 02601
CONTACT PERSON:
EMERGENCY CONTACT TELEPHO E NUMBER: ^1 I — q a-c5
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalling, 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
you store:
Quantity/Case 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 L�
° hey 0 3' 8
-1 S�� 5�ra.y 5 t9
Motor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
Diesel fuel, kerosene, #2 heating oil Pesticides(insecticides, herbicides, ``
Other petroleum products: grease, lubricants rode nticides)�'3, 'F\`t ;�,� .,, seJ
Degreasers for engines and metal Photochernicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) 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)
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 (pleas list):
(dry cleaners)
b • Other cleaning _
ea solvents Gt
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Bug and tar removers ii L. �S J ,►600 05
Household cleansers, oven cleaners ,
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Date:
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: Heart Center, P.C. (d/b/a Heart Center)
BUSINESS LOCATION: 52 Park Street, Hyannis, MA '02601
MAILINGADDRESS: same Mail To:
TELEPHONE NUMBER: (508) 771-4205 Board of Health
Town of Barnstable
CONTACTP.ERSON: P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601
TYPEOFBUSINESS: professional ona medical services
Does your firm store any of the to ' or hazardous materials listed below, either for sale or for you own
use? 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 otherthan 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
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
Antifreeze(for gasoline or coolant systems) Drain cleaners
l NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
begreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
Car waxes and polishes Leather dyes
Asphalt & roofing tar Fertilizers
Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
Paint brush cleaners (including chloroform, formaldehyde,
Floor& furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers: Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):.
Spot removers & cleaning fluids
(dry cleaners) i
Other cleaning solvents
Bug and tar removers t
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS