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HomeMy WebLinkAbout0097 STERLING ROAD - Health (2) 10 GROUSE LANE (HYANNIS) A=268-204 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Grouse LN Hyannis, MA A Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is required for 610 Skunknet RD Centerville MA 02632 9-10-08 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Inn portant: A. General Information When filling out forms on the J (p(J computer, use 1. Inspector: only the tab key to move your Darrell Stone cursor-do not Name of Inspector use the return key:. Cape Cod Septic Inspection Company Name PO Box 1466 Company Address Harwich MA 02645 City/Town State Zip Code 508-240-2500 S14995 Telephone Number License Number B. Certification 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. l am a DEP approved system inspector pursuant to Sectio69- 5.340of !_ Title 5(310 CMR 15.000).The system: N ® Pa ❑ Conditionally Passes ❑ al s c , CD ❑ ds F rther Eval atio the ocal roving Authority o' 1 9-20-08 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. 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 DEP. The original should be sent to the system owner and copies sent to the buyer, if,applicable, and the approving authority. `****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Grouse LN-10 03/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 1 of 15,. µ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Grouse LN Hyannis, MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is required for 610 Skunknet RD Centerville MA 02632 9-10-08 every page. CityfTown State Zip Code : Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete aR of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Septic Tank was pumped after inspection B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will M pass inspection if(with approval of Board of Health): El broken,pipe(s) are replaced I obstruction is removed r❑ s Grouse LN-10.03/08 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Grouse LN Hyannis, MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is required for 610 Skunknet RD Centerville MA 02632 9-10-08 every page. CitylTown State Zip Code ' Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 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 ND Explain: 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 public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, 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 any) u determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Grouse LN-10.03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection form f, a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Grouse LN Hyannis, MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is required for 610 Skunknet RD Centerville MA 02632 9-10-08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: * This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ' El ® Backup of sewage into facility or system component due to 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 SAS or cesspool El ® 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 '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Grouse LN-10.03108 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form R' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Grouse LN Hyannis, MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information for ormation is 610 Skunknet RD Centerville MA 02632 9-10-08 required every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis ' and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to eacht of the following, in addition to the questions in Section D. Yes No ❑ Z 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Grouse LN-10.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Grouse LN Hyannis, MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is required for 610 Skunknet RD Centerville MA 02632 9-10-08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Grouse LN-10.03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 F - i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •''a 10 Grouse LN Hyannis, MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is required for 610 Skunknet RD Centerville MA 02632 9-10-08 every page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd;x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? El Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Sump pump? ❑ Yes ® No 8-08 Last date of occupancy: Date Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design.flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Grouse LN-10•.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form No t for Voluntar y Assessments 10 Grouse LN Hyannis, MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is required for 610 Skunknet RD Centerville MA 02632 : 9-10-08 every page. City/Town State Zip Code Date of inspection- D. System Information (cont.) General Information Pumping Records: Source of information: Discount Septic Pumping Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Weight Reason for pumping: Main. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. El Other(describe): Approximate age of all components, date installed (if known) and source of information: 1972 Assumed Were sewage odors detected when arriving at'the site? ❑ Yes ® No Grouse LN-10.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 I commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Grouse LN Hyannis, MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is required for 610 Skunknet RD Centerville MA 02632. 9-10-08 every page. Cltyrrown State Zip Code Date of In D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 29" feet Material of construction: Elcast iron ❑40 PVC ® other(explain): Orangeburg Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage; etc.): Apparent good condition Septic Tank(locate on site plan): Depth below grade: 24' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years g y p ( copy ) ❑ Yes ❑ No Is age confirmed b a Certificate of Compliance? attach a co of certificate -------- - Dimensions: 1000 Gallon Sludge depth: ` 24" - .. Distance from top of sludge to bottom of outlet tee or baffle 8" Scum thickness 1/2'' Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Sludge Judge Grouse LN-10.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts t! - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 10 Grouse LN Hyannis MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is r equired for 610 Skunknet RD Centerville MA 02632 9-10-08 every page. City/Town' State Zip Codel Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): - Grade to inlet cover 8" Outlet 8" Normal liquid level No sign of leakage SCH 40 outlet tee Recommended pumping eve 2-3 yrs Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grader Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Grouse LN-10.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments M 10 Grouse LN Hyannis MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is required for 610 Skunknet RD Centerville MA 02632 9-10-08 every page. Cityrrown State` Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: El Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attach ed? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): I Depth of liquid level above outlet invert Comments (note if box is'level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No D-box encountered Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Grouse LN-10.03/08 Title 5 official Inspection,Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Grouse LN Hyannis, MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is required for 610 Skunknet RD Centerville MA 02632 9-10-08 every page. City/Town State Zip Code Date of Inspection , D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits- number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level'of ponding, damp soil, condition of vegetation, etc.): 1,(5X6) block pit with >1',stone Grade to pit 26" Cover 8" Bottom 122" Effective Depth 6' Ponding 11" High staining @ 24"from bottom No sign of Hydraulic Failure Grouse LN-10.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts a. r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 10 Grouse LN Hyannis, MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owners Name information is required for 610 Skunknet RD Centerville MA 02632 9-10-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Grouse LN-10.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Grouse LN Hyannis, MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is required for 610 Skunknet RD Centerville MA 02632 9-10-08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 3 i I r 1� 3 Grouse LN-10.03/08 Titles Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Grouse LN Hyannis, MA Property Address Bill Williams C/O Phyliss Alfieri Owner Owner's Name information is required for 610 Skunknet RD Centerville MA 02632 9-10-08 every page. City/Town State Zip Code Date of Inspection D. System. Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >0.1 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: I ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain:. You must describe how you established the high ground water elevation: Shot Elevations during inspection Top of Foundation (Benchmark) ELV. 50.0 Assumed Bottom of SAS ELV. 38.42 Bottom of Hand Auger 33.92 NWE 9-17-08 Separation 4.5' Adjustment 4.4' MIW-29 Zone C 9.0 August 2008 Separation> 0.1' Grouse LN-10.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 k44 Certified Mail#7006 0810 0000 3525 0090 Town of Barnstable �aF; rti Regulatory Services o� Thomas F. Geiler, Director 8 s Public Health DivisionNA O�� sbg9 ..0� Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Edison Herrera May 30, 2007 10 Grouse Lane Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II- MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION. The property owned by you located at 10 Grouse Lane, Hyannis, was inspected on March 22, 2007 by David W. Stanton R.S., Health Inspector for the Town of Barnstable because of a complaint. The following violation of the State Sanitary Code was observed: 105 CMR 410.450: Means of Egress: Adequate egress was not provided in the basement dwelling unit per the Massachusetts State Building Code. The code reads specifically: "105 CMR 410.450: Means of Egress: Every dwelling unit, and rooming unit shall have as many means of exit as will allow for the safe passage of all people in accordance with 780 CMR 104.0, 105.1, and 805.0 of the Massachusetts State Building Code." However, it is noted that the correct reference to the Massachusetts State Building Code for egress is 780 CMR 102, 103, and 1010. A mattress was observed in a room in the basement that did not have adequate egress. You are ordered to correct the violation listed above within Five (5) days of your receipt of this notice, by removing the mattress from the basement room and ensuring that no person(s) sleep in the basement. You may request a hearing before the Board of Health if written petition requesting same is received. Non-compliance will result in criminal complaint being issued against you. OF T E BOARD OF HEALTH Thomas A. McKean, R.S. Director of Public Health Town of Barnstable . QA Order letters\Housing violations\10 Grouse Lane.doc 44'— FREC 91iE 2r,F 96VTROY WILLIAMS '7 2001 SEPTIC INSPECTIONS ARNSTABt E Certified by MA Department of Environmental Protection (508 85-1500 19 Hummel Drive South Dennis, NIA 02660 COMMONWEALTH OF MASSACHUSE'I"I'S EXECUTIVE, OFFICE OF ENVIRONMENTAI, AFFAIRS DEPARTMENT OF ENVIRONMENTAL, PROTECTION IS TITLE s OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 10 Grouse Lane West Hyannisport, MA Owner's Name: Alma Nowak Owner's Address: c/o Suzanne Nowak, 55 Spruce Street Hyannis,MA 02601 Date of Inspection: April 25, 2001 Name of Inspector: Troy M. Williams Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive Telephone Number: South Dennis,MA 02660 (508) 385-1300 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system Passes Conditionally Passes Needs Further Evaluation by the l-ocal Approving Authom) Fails Inspector's Signature: ,, � ;�� Pate: y/.,s /d r The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth or DEP)within 30 days of completing this inspection. 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 DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. •`•"This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 pace I Page 2 of OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 10 Grouse Lane Property Address: West Hyannisport,MA Owner: Anna Nowak Date of Inspection: April 25, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1 have not found any information which indicates that any of the failure criteria described in 3 10 CNIR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below, Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be placed or repaired. The system, upon completion of the replacement or repair,as approved by the Board o ealth, will pass. Answer yes. no or not determined(Y,N,ND)in the __ for the following statements. 1 'not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whet r metal or not)is structurally unsound,exhibits substantial infiltration.or exfiltration or tank failure is imr neat. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by th oard of Health. *A metal septic tank will pass inspection if it is structurally sound, no eaking and if a Certificate of Compliance indicatinu that the tank is less than 20 years old is available. ND explain: _ Observation of sewage backup or break out or igh static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or une n distribution box. System will pass inspection if(with approval of Board of Health): broken pi e(s)are replaced obst ion is removed dis tbution box is leveled or replaced ND explain: The system require untping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with proval of the Board of Health): . _broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 Grouse Lane West Hyannisport,MA Owner: Anna Nowak Date of 1wpection' April 25, 2001 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 public health, safety or the environment. I. System Hill pass unless Board of Health determines in accordance with 310 CMR .303(1)(b) that the system is not functioning in a manner which will protect public health,safety a 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 o salt marsh 2. System will fail unless the Board of Health(and Publi ater Supplier,if any)determines that the system is functioning in a manner that protects the pub ' health,safety and environment: _ The system has a septic tank and soil absorp 'on system (SAS)and the SAS is within 100 feet of a surface water supple or tributary to a surface w ter supply. The system has a septic tank and S and the SAS is within a Zone 1 of a public water supply. The system has aseptic tank d SAS and the SAS is within 50 feet of a private water supply well. The system has a septi ank and SAS and the SAS is less than 100 feet but 50 feet or more froth a private water supply wel . Method used to determine distance **This system pas s if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and vo file organic compounds indicates that the well is free from pollution from that facility and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure cr' ria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 10 Grouse Lane Property Address: West Hyannisport,MA Anna Nowak Owner: April 25, 2001 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate."yes"or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to 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 clogL,.ed SAS or cesspool j Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ,vj Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. NIA Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N//; Any portion of a cesspool or privy is within a"Zone I of a public well. _ �,p,- Any portion of a cesspool or privy is within 50 feet of a private water supply well. Aq, 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 �%atcr quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) /O (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as dr�,crihed in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility w' a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to th criteria above) yes no _ the system is within 400 feet of a surface dr' -ing water supply the system is within 200 feet of a trib to a surface drinking water supply the system is located in a nitrog sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water sup y well If you have answered"yes"to an uestion in Section E the system is considered a significant threat,or answered "yes" in Section D above the I ge system has failed. The owner or operator of any large system considered a significant threat under Sect' n E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system own should contact the appropriate regional office of the Department. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 Grouse Lane West Hyannisport,MA Owner: Anna Nowak Date of Inspection: April 25, 2001 Check if the following have been done. You must indicate`yes"or"no"as to each of the followine: Yes No information was provided by the owner. occupant, or Board of I ieslth _ Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? _ vhi Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up _ Was the site inspected for signs of break out? - _ Were all system components,excluding the SAS, located on site ? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information. For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)) 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Grouse Lane West Hyannisport,NIA Owner: Anna Nowak Date of Inspection: April 25, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3.3 U Number of current residents: S Does residence have a garbage grinder(yes or no): No Is laundn on a separate sewage system (yes o no):No [if yes separate inspection required] Laundry system inspected(yes or no):_&Iq Seasonal use: (yes or no): Aep Water meter readings, if available(last 2 years usage(gpd)): 0o Sump pump(yes or no):qo Last date of occupancy: C-0 , . COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): _ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system es or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: . a �j_s .�. __..: __y��,.� ✓^4� Was system pumped as pan of the inspection(yes or no):dim If yes, volume pumped: _gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distfibutien be*,soil absorption system _Single cesspool _Overflow cesspool _ Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe):. Approximate age of all components. date installed(if known)and source of information: r i y i a I 1+ 1122 Were sewage odors detected when arriving at the site(yes or no):No 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Grouse Lane West Hyannisport,MA Owner: Anna Nowak Date of Inspection: April 25,2001 BUILDING SEWER(locate on site plan) Depth below grade: 4 Materials of construction: _cast iron /40 PVC other(explain): )i h+ -f" Dittanc:- fron. pri\ate water supply well or suction line: N//g Comments(on condition of joints,venting,evidence of leakage,etc.): molt ?4 V L I.0 Cam✓ q.} -{-(�� t�w.�..� u ' /N S/fie G 77 J . SEPTIC TANK: (locate on site plan) Depth below grade: I ' Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: S 'X9 'x6 ' /000 yg /lah . Sludge depth: y' _ _ Distance from top of sludge to bottom of outlet tee or baffle: a ,9 „ Scum thickness:--7-4;N 1,y ,- Distance from top of scum to top of outlet tee or baffle: 4 " Distance from bottom of scum to bottom of outlet tee or baffle: /I/ How were dimensions determined: pn,�6, _ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,, evidence of leakage, etc.): _�.. ��/��—��� h..../a r yCt ..,y. _czc�.�L�✓:. NAG✓ �.cr.c.i a�LG�v� .� O✓__rJ' G-c,/t '�P 4-- GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass yethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of o/etc.): l .Distance from bottom of scum to bot or baffle:Date of last pumping: Cotttments(on pumping recommendoutlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence o 7 Page 8 of l l OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Grouse Lane West Hyannisport,MA Owner: Anna Nowak Date of Inspection: April 25, 2001 TIGHT or HOLDING TANK: (tank must be pumped at time of in ection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flo�� gallons/day Alarm present(yes or no): Alarm level: Alarm in working or yes or no): Date of last pumping: Comments(condition of alarm and float itches, etc.): DISTRIBUTION BOX:N[,(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): r 9 4- -i h PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,conditi of pumps and appurtenances,etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Grouse Lane West Hyannisport,MA Owner: Anna Nowak Date of Inspection: April 25, 2001 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why 1 /1 t�<.� 'f ✓� 'I'"G S h u k-� � .c �u✓4- w I' •e�t t r.�c�^..,.( lau Z.I 6o„✓. a}fit.-. �-<c� Tc--Aro l.,.� c:✓ -� or 4- W� nry.� 1 Y.� .cti�. au/t+t A jo,n,s- 4-, u61/r c t—d� : r < ✓� i �j4 d,<c.✓y 6r:.,-i � / r t,.cto. ✓A.}i v-)'[.,�- rJu..�,� b.c c� 6viJ..�.. c..., 1�.�».< Uw v....i aA T� •f-<-w.�r.� �i'c•..r o�-i.. -�) ..o-r,r�t..:r..r leaching pits,number: I b leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Sa I ,J w t S a.. y —A ru Icy W c.1 L .A n� �. 4L f o:-I-- G � � -c h c w r.� Gt✓u a. .�4 I h 11 U n- �l C ro u ti r h.¢ S ,/� r T—T �.. � Lv✓o.y' tit O h �^ 'f- "/1.c /•+..1c u 7�'. .. t p/.'� L�.. .tnL�. „(,,may.,,,, �p, .<.d L✓ 5�,<..p 1...c.. �- -t'S..� NJ �;u.�-�-� t V L Ny./�/L�-.�l I r u ^YD.. (J/t hJ�-5 pry <^/' 4 t 1`� 4� .1 t u.0 'A.S�oc CESSPOOLS: (cesspool must be pumped as part of inspection)(1 ate on site plan) A! 1 Selo Aj �t.. {� ✓c,S /oar. r..�o �v: �.�� Number and configuration: , "e-14- e- ih ��; Depth—top of liquid to inlet invert: w�s �+^ , , �, Depth of solids layer: i�r p-��_,y N �j 1,; s �.. 17 r--r�- -f Depth of scrim layer: c�h c� , 4;�., S {� ��d u.f 'A- 4i-- of Dimensions of cesspool: j nJ R -� oU. c:.,dt b y &1 wl«vim� ✓...,s t i �9� Materials of construction: ° �Ilar"`}tt u wo .r�~ / Oti �- Indication of groundwater inflow(yesXno): - i"Sy S}<5,,L-o-A, ��s yrS o I ,�; r�h Comments(note condition of soil,sigulic failure, level of ponding,condition of vegetation,etc.): vr. r.A� PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic adure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 10 Grouse Lane Property Address: West Hyannisport,MA Anna Nowak Owner: April 25, 2001 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. l�w�Ik 2s , 1� 10 Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Grouse Lane West Hyannisport,MA Owner: Anna Nowak Date of Inspection: April 25, 2001 SITE EXAM / Slope Surface water / Check cellar ✓ Shallow wells Estimated depth to ground water St feet Adjusted high ground water elevation " feet Please indicate(check)all methods used to determine the high ground %Hater elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: it,%: You must describe how you established the high ground water elevation: t✓ 2 /<,✓paa.+!U.. 4\ W{.� '1��N -+ ~'`'�' J_�_��_��. ..J c � '� J W cl•�+.r � 1 f- 4 cal.c.��. /� �.S �V/1.�11 K.✓+n L6 c /O.d ' G W st �, c1< ✓/c �a J 1 7y a-+ n�/ �..��1�_i..t L_.'TJ 6i N I•L u�Ci-t-� C�__SC_c—_�.l � ✓\U T b-t / {,<—Gl T iJ L� 7 �'1i � Y'^ ll Town of Barnstable Geographic Information System March 23, 2007 268243 �. #r45 4qJ r ` : lip, 0 Y w jJIM 3. ► N 268263 0 268245 �: ; �,�,;, ,.'��'•: Y _ w+" '�,. :. �` : � 268262 '� �c � # 35 VIA ���,� �i ."" �� � �� -k 'mod;•� _ I • 1W 268264; 268246 r r. s 4, 26.81 # 54 µ , r !•" 268080 3� r ,eel`•' . � � �, � w s DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:268 Parcel:264 - boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel 1"=100'may not meet established map accuracy standards. The parcel lines on this map Owner:HERRERA,EDISON O Total Assessed Value:$259200 are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:0.31 acres Abutters ihl' +E boundaries and do not represent accurate relationships to physical features on the map Location:10 GROUSE LANE such as building locations. Buffer �fr� TOWN OF B RNSTABLE LOCATION Cdc�S� SEWAGE# �s VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY c� I ®o0 LEACHING FACILITY:(type) U�OCI� t .(size) '5X 6 NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 ►SCOOQ'� SQ -iC (��l O - w TOWN OF BARNSTABLE ,i LOCATION SEWAGE # �a VILLAGE 1^I• t--f-.1 a `: `dam.-4— , ASSESSOR'S MAP & LOT,.2 A4`/ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / /l LEACHING FACILITY: (type) 1+`k (size) NO. OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: �aZ Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 -J t 1 :'�..�. s � i ' � Q y c F c. x , � r A.. Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: V,"q F,)nzv1 ra BUSINESS LOCATION: If) f2&Q05jb ue dyA lj S 0igO'er o MAILINGADDRESS: ©< 130K (0,14 iVGT-T' 14 et.➢Ajc-S PneX ow;a ail To: 41 i rd of Health TELEPHONE NUMBER: S-dk79O 'es_ lcY'" Town of Barnstable CONTACTPERSON: F Sr)A) (3 , R.Q aeo P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: J�; -0 Z Hyannis, MA 02601 TYPEOFBUSINESS: 160 tT62. (cd Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES c/ 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: e ADDRESS: N iS SU AJ gQJP :STO,g4aP, 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 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 Degreasers 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 Paint brush cleaners Any other products with "poison" labels Floor& furniture strippers (including chloroform, formaldehyde, Metal polishes hydrochloric acid, other acids) l/ 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) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS I �Y : m n Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: InQ.2 c&22.uiA Q ZV I C'(B! BUSINESS LOCATION: /f2E(Da5r- /9A)a /-//, ,O/J;s w oz(oo/ MAILINGADDRESS: 0. 30 X (0�2 VUG�-T 14 UkU;,� bZ 0 ;,,Pail To: TELEPHONE NUMBER: '70k79 J Z S_ S 'Board of Health Town of Barnstable CONTACT PERSON,: �: i:c/SnAj r3 d&_,R 20, Ca P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: C ZO L 2 kC� Z 7&f: Hyannis, MA 02601 TYPE OF BUSINESS: ;Tt9 N I TOy i a l t .Does your firm store any of the toxic 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 ayes 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: #"/4/uN ; S SU AU TELEPHONE: SUS" 790 / S'S` Z.- 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. f Quantity Quantity Antif reeze(for gasoline or coolant systems) Drain cleaners 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 Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine i 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 Paint brush cleaners Any other products with "poison" labels (including chloroform, formaldehyde, 64 Floor & furniture strippers Gam" Metal polishes hydrochloric acid, other acids) 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) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS F J r i . j F .15 i Vk' 't J - :a ,• a ,y, (j r J{ft 144 ice} � i/ A�� �q a :l � C l '7 i' 3 r + f I b a;�