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HomeMy WebLinkAbout0431 YARMOUTH ROAD - Health (2) 431 YARMOUTH ROAD HYANNIS A = l� 'I i I I� TOWN OF BARNSTABLE V f` WLOCAn k0l 5�1�elv � 9 46E # VILLAGE a ASSESSOR'S MAP & LOT SEPTIC TANK CAPACITY 040 LEACHING FACILITY: (type)! (size) >. NO.OF BEDROOMSjO BUILDER OR OWNER k94" 29M&i PERMTTDATE: 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 fee ochin acility)� Feet . Furnished by �� b i J p ;fly a y�- TOWN OF BARNSTABLE Date:V) /30/1-5' TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: e � 4a� C f (4 e L j - 7/:*-�-W BUSINESS LOCATION: L t? r � R6 INVENTORY MAILING ADDRESS: To -Box `7 o� � Q "z L y 1 TOTAL AMOUNT- TELEPHONE NUMBER: 7 — L - Z � CONTACT PERSON: (/� � EMERGENCY CONTACT TELEPHONE NUMBER: S(� ��1?. MSDS ON SITE? TYPE OF BUSINESS: Sep 0d CJG 4311 e INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Photochemicals (Fixers) Gasoline, Jet fuel,Aviation gas Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison"labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents i Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applic Signature Staff's Initials YOU WISH TO OPEN A BUSINESS? f, For Your Information: Business certificates (cost$HO.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you roust do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) �rrt.' : .. ;:f.,,��. _r�.:,�r,,,,.._ DATE: � Fill in pl ase: �54�r ^a.lr�..ti nuf.:.iglu t1,i;.N'•nm �t t>tr;� ,lci°rs=a+..; ,, 2�° :..=. . APPLICANT'S YOUR NAME/S: , a r a-� ry BUSINESS YOUR HOME ADDRESS: O U X �q Z CO FaO i 7 11 j 2 '$ 'n.F a r� TELEPHONE # Home Telephone Number 1 �� Zq 7 NAME OF CORPORATION: 14 SS NAME OF NEW BUSINESS 6 i K-e- VLA-O r a C;4 eo jrujWYPE OF BUSINESS e e J.A k eJ e IS'THIS A HOME OCCUPATION? YES NO nn ADDRESS OF BUSINESS PD Z:) Q 1 2- 2 O Z bC) l MAP/PARCEL NUMBER !1�� (Assessing] When starting a new uusiness there are several mings you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth, Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has n,info ed of y ermit requirements that pertain to this type of business. Authorized Signature_ * COMMENTS: r` 2. BOARD OF HEALTH MAST-COMPLY WITH ALL 'This individual has nfor e f the p mit re irements that pertain to this type of busirHj�RDOVS MATERIALS REGI)LATIONS Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $40.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town (WHICH YOU MUST DO according to M.G.L. - it does not give you permission to operate). You must first obtain the necessary signatures on this form at 200 Main St.; Hyannis. Take the completed form to the Town Clerk's Office, 19t FI., 367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law. j Fill in please: DATE P Fnf APPLICANT'S YOUR NAME/CORPORATE AME ' EUSINESS TYPE: I BU I ES ^�n YOUR HOME ADDRESS: S TELEP ONE #� Home Tele hon Numbe NAME OF NEW BUSINESS , Have you been given appr val fro .the building divi ? YES NO ADDRESS OF BUSINESS MAP/PARCEL NUMBER 1/3f When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. �- (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual han beep inform d f piny er it requirements that pertain to this type of business. Auth rized Signs ur COMMENTS: 2. BOARD OF HEALTH This individual has bee nform d of h permi requirements that pertain to this type of business. ti uthori d Signature` COMMENTS: p /a,t �,��GGz� ��,¢�-yL� �S TO BE LCSE�STa2cD o.tJ SITE Au A-L—eS 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: Hazardous Materials Inventory Sheet Checklist .� Date V' Physical Street Address-Check database'to ensure it exists / Working Phone Number _Actual Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials-no blanks) Storage Information -location of storage, how long is storage for? If none, note that. Disposal Information -where and who? If none, note that. Applicant Signature -understand what is listed and noted Staff Initial -any questions, know who to ask _Vehicle Washing/Rinsing? -give a vehicle washing policy and explain it ✓ Attach.the Business Certificate with your sign off and comments **The inventory form.should explain what the business.consists of and the procedures = t h i l they are doing.: Notes need to be left to explain what you-discussed with them. P. ,. y ,. . .:.:. ;.,. .: ..: • `' Dater 12 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: q INVENTORY MAILING ADDRESS: ZZZ YA4,111121 (Z Q NyAI'v"I ,h0a el zee i TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: _�,,, S..gLe s INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) I Miscellaneous Corrosive ❑ NEW ❑ USED (ODCesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED ,ri (insecticides, herbicides, rodenticides) �© Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) (� lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) /110 Caulk/Grout ,U Swimming pool chlorine 11/0 Battery acid (electrolyte)/Batteries Lye or caustic soda W6 Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) 0 Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers p (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS PPlicant's Signature Staff's Initials YOU WISH TO OPEN A BUSINESS? tears). form at 200 A business certificate ONLY REGISTERS� ` YOUR NAME in town which{Hyannis. erate. You must first obtain the necessary sigi For Your Information: Business ceouifice�mission to op 00 for y o b M.G.L.-it does.not give y p e 1st FI., 367 Main St., Hyannis, N1A 02601 (Town Hall) and get the Business Certificate that-is must d Y Take the completed form to the Town Caerk's office, required by law. �I Fill in please: DATE: fy -W' APPLICANT'S YOUR NAME/S: m a � ��d� S YOUR HOME ADDR : 2— BUSINESS - 3 k TELEPHONE # Home hone Number Telephone �� SS NAME OF CORPORATION TYPE OF BUSINESS N NAME OF'NEW BUSINESS PARCEL NUMBER ;. {Ass.essin IS THIS A HOME OCCUPATIO � Y S r Q� MAP/ ADD., S&OF BUSINESS`. Hance with the rules and regulations of the Town of �3 you must do in order to be in comp corner of Yarmouth need. You MUST GO TO a ous Hess in this town. When starting a new business there are several thingaining s Y inform and licenses required to legally ap your Barnstable. This form is intended dude o assist have the appropriate pinfor s and you may Rd. & Main Street) to makeY erm BUILDING COMMISSIONER'S OFFICE erm This individual ha it requirements that pertain to this type of business. 1. s been informed of any p Authorized Signature** 3� 5,� COMMENTS: LoG I !/ / r� Ktg No; o.V'E' ,¢T FSu.�i.vtS3o 9�S'Z� D OF HEALTH ` rements that pertain to this type of business. [s%ta e u nook e�tu s w�� 2. BOAR e n infor ed o the e mit r This individual h Authorized nature** MUST cOMPLYVMALL TIONS COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) pertain to this type of business. This individual has been informed of the licensing requirements that Authorized Signature* COMMENTS: Date Physical Street Address-Check database to ensure it exists �sWorking Phone Number _Actual Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials-no blanks) Storage Information -location of storage, how long is storage for? If nor s, note that. Disposal Information -where and who? If none, note that. Applicant Signature -understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -give a vehicle washing policy-and _20el�plain it Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. � TOWN OF BARNSTABLE Date: / V IdQ f/ TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: NICC-09 009hkCa6 BUSINESS LOCATION: INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: U EMERGENCY CONTACT TELEPHONE NUMBER: ag5 MSDS ON SITE? TYPE OF BUSINESS: r IN FORMATION/RECOM MEN DATIONS�'w WfflfV Fire District: �&T( � � Waste Transportation: Nov, Last shipment of hazardous waste: Name of Hauler: NOM Destination: k} Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils 3gvA*- Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt&.roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, 11 Lacquer thinners I W (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison".labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishesfA A I Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) ' i Other cleaning solvents Bug and tar removers Windshield washy 6N(m WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials i� ��u "_ � ��,�, � �Q��i� �,,� �� Hazardous Materials Inventory Sheet Checklist Date 'Mysical Street Address-Check database,to ensure it exists Working Phone.Number- Actual Amounts - ( ie. gas being used.to fuel machines, thinner to clean brushes all count as hazardous materials-no blanks) Storage Information - location of storage, how long is storage for? If none, note that. !/ Disposal Information -where and who? If none, note that. . Applicant Signature - understand what is listed and noted taff Initial -any questions, know who to ask Vehicle Washing/Rinsing?. .give a vehicle washing policy and explain it Attach the Business Certificate with your sign off and comments 'ventory form should explain what the business consists of and the procedures ,ing. Notes need to be left to explain what you discussed with them. ,c . Date: 5 195/ iQ - TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: G c . r BUSINESS LOCATION: ght V01CM00-M (,Lwif INVENTORY MAILING ADDRESS: o nn L KA TOTAL AMO NI.;' TELEPHONE NUMBER: a CONTACT PERSON HU. `6 2 b EMERGENCY CONTACT T LEP ONE NUMBER: I�1 MSDS ON SITE? TYPE OF BUSINESS: O INFORMATION/RECOMMENDATIONS: Fire District: o Waste Transportation: LLOCe Last shipment of hazardous.waste: Name of Hauler: 6?2:1'Q _ Destination: k�0 Waste Product: I'1X)np Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils aquock Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible b �? Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash 13al(cr ' WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS YOU WISH TO OPEN A BUSINESS? For Y our Information: Business certificates (cost$30.00 for.4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1" FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) s DATE 0 "tsNy"r{t s€,. "t''�=ex r [III e se: s4 tir+ n1 w�� APPLICANT'S YOUR NAME/S: v 4Ps �a� � � BUSINESS �OSSGn��" Guct � H YOUR HOME ADDRESS: Nj , . "3` r �a PIN 1 Kulv ff UP, '` d4"" Ay3a TELEPHONE # Home Telephone Number 1 O NAME`OF CORPORATION: NAME OF.NEW.BUSINESS TYPE OF.BUSINESS IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS MAP/PARCEL NUMBER (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town'of Barnstd'ble. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has n i formed any permit requirements that pertain to this type of business. . Authorized Signature COMMENTS: 22 0 2. BOARD OF HEALTH _ This individual has b form f t e p mit r em nts that pertain to this type of business. thor' `ed Signatur MUST COMPLY NTH ALL COMMENTS: HAZARDOUS MATERIALS REGIKATIMI-, 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. COMMENTS: Authorized Signature'" k IJI�II they are doing. Notes need to be left to explain what you discussed with them. Hazardo-s Materials Inventory Sheet Checklist Date Physical Street Address-Check database to ensure it exists orking Phone Number Actual Amounts -( i.e. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials-no blanks) Storage Information - location of storage, how long 9 is storage for? Z none, note that.. Disposal Information -where and who? If none, note that. 4/Applicant Signature -understand what is listed and noted `Staff Initial -any questions, know who to ask Veh 'Washing/Rinsing? give a vehicle washing policy and xplain it Attach the Business Certificate with your sign off and comments **The inventory form should explain what the hi Icir ...,r .... .. S^. 0 ` ?'.,: Date: 5 45/1O. all. TOWN OF BARNSTABL TOXIC AND HAZ RDOUS MATERIALS O'N-SITE INVENTORY NAME OF BUSINESS; BUSINESS LOCATION: rnOU G11 INVENTORY MAILING ADDRESS: MG KID I(lr'l15 A= TOTAL AMO NT: TELEPHONE NUMBER: �� �PF I .S 01 CONTACT PERSON: EMERGENCYCON TACT T LEP ONENUMBE � � 1`741.J KSDS,fON SITE? TYPE OF.BUSINESS: ! U �O /� 0 6_. OS= INFORMATION/RECOMMENDATIONS T S`O I'1 Fire District: C--G 5 v Q ;Q\T t, Waste Transportation: one Last shipment of hazardous waste: Name of Hauler: I Destination:. Ilia " Waste Product: I'L'O Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31,, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. . . . LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health-Division have determined'that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. . Observed/Maximum Observed/Maximum _ Antifreeze (for gasoline or coolant.systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including_brake fluid) Refrigerants Motor Oils _�quo its Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW -USED Misc. petroleum products: grease, Photochemicals-(Developer) lubricants, gear oil NEW USED Degreasers for engines,and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car.waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, a- - Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor& furniture strippers Other products not listed which you feel Metal polishes „ may be toxic or hazardous (please`Jlis "' Laundry soil & stain removers (including bleach) Spot removers& cleaning fluids (dry cleaners) j Other cleaning solvents uQ. Bug and tar removers ' Windshield wash r'9Q 4n WHITE.COPY-HEALTH,DEPARTMENT/CANARY COPY-BUSINESS 18/ DATE:____1/1 99_ PROPERTY ADDRESS: 1_ Yramouthh—Road —_ Hyannis _Mass__ 02601 ------------------------ On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1-1000 gallon septic tank. - y 2 . Remainder of the septic system is under the asphalt parking lot . Based on my Inspection, I certify the following conditions: 3. This is a title five septic system. ( 78 Code ) 4 . The septic system is in proper working order at the present time . SIGNATURE: 1 N a m e:_,L L,Ao-gsmktL.sLr------- Company; Jose-ph_P_ Macomber & Son , Inc . Address: Box 66 j __CentervilleL M_a_-02632-0066 Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY LP. MACOMBER & SON, INC. f0anks-Cesspools-LeachfieidsPumped & Installed F N0i/ 2 2 1999 Town Sewer Connections 66 Centerville, MA 02632_0 "NOFNAVS 775.3338 775-6412 y M1AL-,%C PTAB� • S \ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENvIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVM B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 431, Yarmouth Road Name of Owner Arthur E. Andres Hyannis M a s g Q 2 9 Address of Owner: Data of Inspection: 1 1/1 �9 Name of Inspector:(Please Print) Joseph P.Macomber J r . I am a DEP approved system inspector pursuant to Section 15.340 of Thle 5(310 CMR 15.000) company Name: J.P.Macomber & Son Inc . Marring Address: Rnx 66 Centerville Mass —09632 Telephone Number: c n o c o 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 Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails / Inspector's Signature: . r Date: The System Inspecto all submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(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 Department ofrEnvironmetrial Protection. The original should•be sent to-" system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS 1 . Septic system is under the -Asphalt parking lot . 2 . One tank cover is raised to grade . " 3. This shows that the tank is at operating level : 4 , The SAS was not located . It is under the asphalt parking lot . 5. The S*hould . be located and cast iron rings be installed to the existing grade. t revised 9/2/98 page lorn �1 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 431 Yarmouth Road Hyannis ,Mass . Owner: Arthur E. Andres Date of Inspection: 1 1/1 8/9 9 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: a 0 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.. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. ,V The septic tank is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached) Indicating that the tank was Installed within twenty(20) years prior to the date of the Inspection; or the septic tank, whether or not metal, is 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 complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or 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 levelled or replaced The system required pumphig-more then'fourtimes s yeardue to broken or obstructed pipe(s). The system wilh mr-- Inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed revised 9/2/98 Page 2orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: A r t u r E. Andres Owner: 431 Yarmouth Road Hyannis ,Mass . Date of Inspection:11/18/9 9 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: —kb 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 IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.YALL.PROL7MCT THE PUBLIC HEALTR AND SAFETY AND THE ENWRONMENT- Cesspool or privy is within 50 feet-of surface water AD 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)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Al� 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. yf The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS Is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance otI4 (approximation not valid).- 3) OTHER A1,4 revised 9/2/98 Page 3of11 c4. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddreas: 431 Yarmouth Road Hyannis ,Mass . Owner: Arthur E. Andres Date of Inspection: 1 1/1 8/9 9 D. SYSTEM FAILS: You must Indicate either "Yes" or"No" to each of the following: , !e I have determined that one or more of the following failure conditions exist as described 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. Yes No fr/ Backup of-sewage iMofeciRty"or-•system componerMdueqo an overloaded orckggedSAS-or-cesapool. =�---�• Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or ��// cesspool. llwAleurA1 ,Y Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. �OLC JJc Liquid depth in cesspool is less than 6" below Invert or available volume(s less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 1 ll�1L /Ql6°d� 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 I 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. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: .o _ 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: Yes No , L/ the system is within 400 feet of a surface drinking water supply the system•is-within 200€aetoiet+7butarYtoasurfaoedrkrtciwgwatersupply• - -- - 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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inforInation. revised 9/2/98 Page 4of11 1 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prop"Address: 431 Yarmouth Road: TYannis ,Mass . owner: Arthur E. Andres Date of Inspection:1 1/18/9 9 Check if the following have been done:You must Indicate either "Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health. — None of the aystem•cornpoaant.s kaaaj bean puw4ped4orpscJeast two•awo&k*and tha'rystom hasbaeoascaiaiag*AWWW Clow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this Inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. IV/ — All system components excludin the S bsor lion System, ave been located on the site. — 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. The size and location of the Soil Absorption System orrthe site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation f distance is unacceptable)) y� 115.302(3)(b)) V — The facility owam.tand.accups—n!Q.•jf dlfferflGt tfDa1.018IIIeJJsIHarB.plIILldall.lMil}�lnfnrmnti pn t npor rnaintnnn.v ..f SubSurface Disposal Systems. I 1 I revised 9/2/98 page sorii i t vs SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 431 Yarmouth Road . Hyannis ,Mass . Ownel Arthur E. Andres Date of Inspection:11/18/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: AM g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actuap:_ Total DESIGN flow Number of current rom ents2 Garbage grinder(yes or no):_ Laundry(separate system) (yes or no):d/A; If yes, separatainspaction.required Laundry system Inspected I a or4o Seasonal use(yes or no):� Water meter readings,if avail ble(last two year's usage(gpd): Sump Pump(yes or no): Last date of occupancy: COMM ER CIALAN DUSTRIAL-* / Type of establishment: �fdT' Design flow: I d ( Based on 1 b.203) S%� �/�� Basis of design flow 1 k A1,4 A Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no)d Non-sanitary waste discharged to the tl system:(yes or no) Water meter readings,if avail b 0 4;ie Last date of oc cup ancy:�� OTHER:(Describe) A�. Last date of occupancy: f GENERAL INFORMATION PUMPING RECORDS and ur a of Informs n: 7. If, i� System pumped as part of inspysay�cti—on: (yes or no if yes, volume pumped: 11 gallons Reason for pumping: f TYPE OF SYS e tic tank distribution boxlsoil absorption system f�y191`)1�Y tP 6.4 ys Ingle cesspool Overflow cesspool AA Privy A. Shared system(yes or no) (if yes, attach previous Inspection records,if any) I/A Technology et .Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval �T Other APPROXIMATE AGE of ail comp nents, date i t gediif own•an sour of4nformation: .V Two ��•4 �s Sewage odors detected when•arriving at the site: (yes or no) revised 9/2/98 Page 6of11 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) prop,rtyAd&,U:431 Yarmouth Road Hy,annis.,Mass . Owner: Arthur E, Andres Date of Inspection: 1 1/1 8/9 9 BUILDING SEWER: (Locate on site plan) Depth below grade:/ Material of construction: cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter IV it Comments: (condition of joints, venting,evidence of feakage,-etc.) - -- Joints aDDear tight , No Pyidpmr-p of 1PAkggP gygtPm vefiteri thrmmgh the £AA-f Veat r SEPTIC TANK:— (locate on site plan) Depth below grader' Material of construction:kconcrete_metal_Fiberglass _Polyethylene_other(explaln) If tank is metal, list age_ 13.age.confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: 00 Distance from top of sludge to bottom of outlet tee vrtaffie. Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto of outle tee or baffler How dimensions were determined: 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.) Pump tank anually - Tnlet tPP ig in IlarP _ ThP rank gt-r11rt-iirn11 v C2031nd and g]}61Jg aw e;,xi dP r-P of lealeage -Outlet end of- tank is tiader the asphait . GREASE TRAP: (locate on site plan) Depth below grade: Material of constructionmconcrete(JlmetalAFiberglassAAPolyethyleneN6other(explain) Dimensions: Scum thickness:—A Distance from top of scum to top of outlet tee or baffle:-z&!t Distance from bottom of scum to bottom of outlet tee or baffle:, Date of last pumping: 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.) Grease trap is not present revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropectyAddress: 431 Yarmouth Road Hyannis ,Mass . Owner: Arthur E. Andres Date of hupection: 11/18/9 9 TIGHT OR HOLDING TANK; L (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction:,VAconcreteA&metalAAFiberglass4 Polyethylene*Qother(explain) AJA AJA - -- _ Dimensions: kf9 Capaclllons Design gaallon Design flow: gallons/day Alarm present�/� Alarm level:--Alarm in working order:YesAO Now Date of previous pumping: AIA _ Comments: (condition of inlet tee, condition of alarm and float switches,etc.) Tight or holding tanks arP not =rPGPnt _ DISTRIBUTION BOX:-U')PA*"j R'9' 417- (locate on site plan) Depth of liquid level above outlet invert: Comments: (note-if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — — Di atri bnt-inn hay is iinrlOS agphg1 t parking -1-t- If tbez:a PUMP CHAMBER:�me- (locate on site plan) Pumps in working order:(Yes or No) AA Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Pump chamber is not present , revised 9/2/98 Page 8of11 n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address.. Yarmouth Road Hyannis ,Mass . owner: Arthur Andres Data of Inspection: 11/18/9 9 SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,If possible;excavation not required,location may be approximated by non-lntruslve methods) If not located,explain: Type �I� `i W1odw A.0 A�jl' leaching pits,number:,��/1�,1� leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool,number: Alternative system: 7 C� Q Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to mpdinm ssnd _No signs of hydraulic failure or �onri; ns� �6�15 are dr--y Asphalt pparSki gmil of No vcoatati nn CESSPOOLS: 11k&61V ) Sys !4yp�► r r (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimenslons of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of Inspection) o esspoo s are not present . Comments: (note condition of soil, signs of hydraulic failure,level of.pending,condition of.vegetation, etc.) Cesspools are not present . PRIVY:&AI (locate on site plan) Materjals of construc on: .C�/� Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation;etc.) Privy isonot present . revised 9/2/98 page 9orii SUBSURFACE SEWAGE DLSPO$AL SYSTN" WSPECflON FORM PART C SYSTEu LNFOR>.tAT10N(c ndrivad) pyop.M A d4i"4: 477 04� 413 Yarmouth Road Hyannis ,Mass . Owrw- Arthur Andres o av 0, 1 1/1 8/9 9 SKETCH OF SEWAGE DISPOSAL SYSTEU: . Include tiss to at least two permanent r►(sr►ncs landmarks or benchmark& locals all wells wlWn 100' (Locals where public water supply comes Into house) i tea. r 1 6-/ , y� revised 9/2/98 PegtlooO) w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAdd.ess: 451 Yarmouth Road Hyannis ,Mass . Owner: Arthur E. Andres Date of Inspection: 1 1/1 8/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 1 5 'Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Xr- Observed.Site(Abutting property, bservation hole, basement sump etc.) Determined from local conditions _zchecked with local Board of health Checked FEMA Maps Checked pumping records �hecked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used Water Contours Map Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11or11 •rm.5r+r,-n•rsr.•+-r-irnrmr•.nnrrr�nrrisrmnr.-.r+inn►r�sr*rmnr+ern•+u++a�rrv..et+ TOWN OF Baingtable .:a ` t6ARD OF HEALTH 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION 1 ^•rr�-r•.._.. -r. r.-.-rrm r.n•rtn+rt rwaes•.rarrrtrrerr*-tvtne�srnbr`r+e*wwurw►w.r�nr,�e� ern •.+vrr•r.--r-r.� -TYPE OR PRINT CI,EARLY- PROPERTY INSPECTED STREET ADDRESS 451 Yarmouth Road Hyannis-,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Arthur E. 'Andres PART D - CERTIFICATION NAME OF INSPECTOR Joseph P .Macomber Jr . COMPANY NAME J.. P.Macomber & Soif 'Inc . COMPANY ADDRESS Box:;66 Centerville ,Mass . 02632 Strout Town or Clty State LIP COMPANY TELEPHONE ( 508 775 - 3338 FAX (508 ) 790 - 1578 R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal, system at this address and that the information reported is true , accurate , and omplete as of the time of -inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : .System PASSED The inspection lihich I have conducted has not found any information which indicates that the system fails to adequately protect public health or Lhe environment as defined in 310 CMR 15 . 303 ► Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con toted has found that the system fails to protect the j-)ublic health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date 3w76 'copy of this certification must be provided to the OWNER the BUYER here applicable ) and the 130ARD OF HEALz'II. * If the inspection FAILED, the owner or'"*operator shall upgrade he aYate within one year of the date of the inspection, unless allowed ortrequiredm otherwise as provided in 3.10 CMR 15 . 305 . partd.doc