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HomeMy WebLinkAbout0711 YARMOUTH ROAD - Health 71fYARMOUTH,ROAD,HYANNIS A= 345 007 i i Ul Go zt7 Commonwealth of Massachusetts Executive Office of Environmental Affairs NoDe artment of � �96 Environmental Protection 19 William F.Weld Tru'dy.Coxa 4o""T0' David B.Struhs Argoo Paul Celluccl Coavn64or.r LL Go.%mor ee SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddi—, 711 Yarmouth Road Hyannis ,Mass . Addreca of owner. 102 Ansel Hallett Road Date of Iaspe4on:4/25/96 (If different) Yarmouth,Mass . 02673 Nameofln.pe°torJoseph P. Mae �mber Jr. Company Na:ne,Addreaa and Telephone umber. J.P.Macomber & Son Inc . Box 66 Centerville ,Mass , 02632 CERTIFICATION STATEMENT 508-775-3338 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and eomplets as of the time o inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on•sita ae ge disposal systems. The system: Passes _ Conditionally Pusses Needs Further Evaluation By the Local Approving Authority —_ Fails Inspector's Sl Date;gnatum �� The System Inspector submit a copy of this inspection report to the Approving Authority 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 of Environmental Protection. The original should be sent to the system owner And copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: AJ SYSTEM PASSES: II have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: 0 One or more system components need to be replaced or repaired. The system, upon oompletion of the replacement or repair, passes inspection. Indicate yes, no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) A)0a., The septic tank is metal,cracked; structurally unsound, shows substantial infiltration or exfrltration,-or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Conforming septic tank as approved �J by the Board of Health. (revised 11/03/95) 1 One Winter Street 0 Boston, Massachusetts 02108 0 FAX(617) $54-1049 9 Telephone (617)292.5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Proporty Address: 711 Yarmouth Road Hyannis ,Mass . 02601 Owner. Dr. L. Venezia Date of Lupootlow 4/2 5/9 6 Bj SYSTEM CONDITIONALLY PASSES(coatiaued) . Sawage backup or breakout or 0 static water level observed in the distribution bout is due to broken or obstructed piper) or due to a broken,settled or unaven distribution box. The system will pass inspection if(with approval of the Board of Health): • broken p!pe(s)are replaced , obstruction is removed distribution boi is lmlled or replaced The system required pumping more than four times aayear due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: �� Conditions exist which require further evaluation by the Board of Health in order to determine if the system Is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PA99 UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS'NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIR.ONMENTt &v Cesspool or privy is with!a 60 feet of a surface water Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh. Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM 13 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: N� The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system bas a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 60 feet of a private water supply wall. The system has a septic tu%k and soil absorption system and is less than 100 feet but 60 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 6 ppm. 9) OTHER 2-61x8l block cesspools . System dry (revised 11103/95; z 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontlnuod) PropertyAddroes: 711 Yarmouth Road Hyannis ,Mass . 02601 Owner: Dr.. L. Venezia Date of Inspootion: 4/25/96 ` DJ SYSTEM FAILSs e kO I have determined that the system violates one or more of the following(allure criteria as darned in 310 CMR 15.303. The basis for this determination is idanti.W below. The Board of Health should be contacted to determine what will be naoaasw7 to oorrect the failure.'; . Backup of sewage into facility or system component due to an overloaded or clogged SAS or Cesspool. LQ Discharge or ponding of effluent to the surface of the tround or surface waters due to an overloaded or clogged SAS or cesspool l2 Static liquid level in the distribution box above outlet invert due to an Overloaded or clogged SAS or cesspool Liquid depth in cesspool it less than 6"below invert or available volume is leas than 1/2 day flow. Q, Raquirod p=plag snore than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 foot 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. �d Any portion of a cosspool or privy is within 60 feet of a private water supply well. &a Any portion of a cesspool or privy is less than 100 feet but greater than 60 foet 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 awdysL for eoliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. Ej LARGE SYSTEM FAILS: Tha following criteria apply to large eysteme in addition to the criteria above: . f The system serves a facility with a deuign flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and tha environment bocause one or more of the following conditions exist: &).04 the system is within 400 feet of a surface drinking water supply AW 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 snapped Zone II of a public water supply wall) The owner or operator of any such system sha.1 bring the system and facility into U Campliaace with the groundwater treatment prov= requirements of 314 CMR 5.00 and 6.00. Plea.a eonoult the local regional ojMce of the Department for further information.. (revised 11/03195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddresx 711 Yarmouth Road Hyannis ,Mass . 02601 Owner. Dr. L. Venezia Date of Inspection: 4/2 5/9 6 s Check if the following have been done: Pumping information was requested of the owner, occupant,and Board of Health. ZNons of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 2As built plans have been obtained and examined. Note if they are not available with N/A IThe facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow 4L/The site was inspected for signs of breakout. ZAll system components,"eluding the Soil Absorption System, have been located on the site. /t6&e-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. ZTbl size and location of the Soil Absorption System on the site has been determined based on existing information or /oprozimated bynon intrusive methods. facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Addreaw 711 Yarmouth Road Hyannis ,Mass . 02601 Owner. Dr. L. Venezia Date of Inspection: 4/2 5/96 FLOW CONDITIONS RESIDENTIAL: Design&w: llons • Number of bedrooms: Number of current residents Garbage grinder(yes or no): Laundry connected to syte,\m`�(yes or ao):Al Seasonal use(yes or no): Water meter readings,if available: Last date of occupancy: COMMERCIAL/INDUSTRIAL jj �/� Type of establishment: fl N l N11�A k W d A 1 l'Acwl Design flow:'�b gallons/day Grease trap present: (yes or no)✓I Industrial Waste Holding Tank present: (yes or no)/L/n Non-sanitarywaste discharged to the Title to es no)N J �. Water mee available: ✓ � t it �P ii1GXi 7� +'P+� b Last date of occupancy: OTHER(Describe) t Last date of occupancy: GENERAL INFORMATION PUMPINCL RECORD and source of' rmation System pumped 'sas part of inspection: (y or no)" If yes,volume pumped:gallons Reason for pumping: A) TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool _dj6 Privy _7�Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: 'Y�)��l Sewage odors detected when arriving at the site: (yes or no)IJ2 (revised 11/03/95) 6 Name: Hyannis Animal iimal Hospital Inc Customer Code: Address: 711 Yarmouth Road i .ho To-on: Hyannis state:Ma zip:02601 Mailing address: 711 Yarmouth Rd Hyannis MA 02601 89-90-91-92 Notes: 1112193 pump 2 pools 230.00 11-'6193 � 4114193 pump 2 pools 230.00 4123193 { 8116193 pump 2 pools 225.00 8125193 12117193 pump LP's 220.00 12131193 3114194 pump 1 pool 145.00 3125194 6116194 p urnp 2 pooIs 245.00 6124194 10117194 pump sirs 230.00 10128194 1116195 pump 2 pools 245.00 1120195 f �II l _x 1 I b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property,ddrea&- 711 Yarmouth Road Hyannis ,Mass . 02601 Owner. Dr. L. Venezia Date of Inspection: 4/2 5/9 6 SEPTIC TAN *A • (locate on site plan) Depth below grade: 09 Material of construction� coacrete_metal_FRP_other(ezplain) Dimensions: Sludge depth: Distance from top of nudge to bottom of outlet tee or baffle:AJ _ Scum thickness:_/01? Distance from top of scum to top of outlet tee or baffle: ti'/`} Distance from bottom of scum to bottom of outlet tee or baffle: !L r Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence 9f leakage,etc.) N is •� .ne�uT, GREASE TRAP: O.v2 (locate on site plan) Depth below grade: Material of¢onstzuction:4-��oncrete_metal_FRP_other(esplain) Dimensions: Scum thickness:_A) Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structured integrity, evidence oj,leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) p,oP,ty Ads; 711 Yarmouth Road .Hyannis ,Mass . 02601 Owner. Dr. L. Venezia n: 6 Date of Ins 2 5 9 Da l�do 4/ / TIGHT OR HOLDING TANK:Ix+.VG; (locate on site plan) Depth below grade: N , Material of construction:&L&oncrets_metal_FItP_other(ezplain) hit N Dimensions:. WA Capacity: allons Design flow: onalday Alarm level: Comments: (condition of inlet We,condition of alarm and float switches,etc.) (; 1 DISTRIBUTION BOX:.,dZ0.0 , (locate on site plan) Depth of liquid level above outlet invert: AM Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER:_),&,VP_ (locate on site plan) Pumps is working order:(yes or no)- Comments: ( co tioa of pump chamber,condition of pumps and appurtenances,etc.) 621 AlP AMS (revised 11/03/95) 7 U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) PropertyAddresa: .711 Yarmouth Road Hyannis ,Mass . 02601 Owner. Dr. L. Venezia Date of Inspection: 4/2 5/9 6 SOIL ABSORPTION SYSTEM (SAS):,Z (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Medium sand to fine sand; leaching pits,number.Q leaching chambers,number: 1":hing galleries,number. leaching trenches, number,length: leaching fields,number,dime ions: overflow cesspool,number: f Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Medium sand to fine sand;No signs of hydraulic failure or ponding Cesspool is in asbhalt parking area . Cesspool is dry CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. Dimens, no of cesspool: Materials of construction: Indication of groundwater: DRY inflow(cesspool must be pumped as part of inspection) Medium sand to finesand;No signs of �fydrnjijj failurp or ponding Cesspools are structurally sound, Cesspools are dry. cpmments:(note ndition oSS soil,signs orr hydraulic failure,level of ponding, condition of vegetation,etc.) Same as move Cesspools are dry PRIVY: ;'V', (locate on site plan) Materials of construction: Dimensions: / W Depth of solids:_Q Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n �flMVJ�'�tll"� i r (revised 1l/03/95)- 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Add: 711 Yarmouth Road Hyannis ,Mass . 02601 Dr. L. Venezia Owner. Date of Inspection:4/2 5/9 6 SKETCH OF SEWAGE DISPOSAL SYSTEM: e include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Hyannis Water Company 775-0063 DEPTH TO GROUNDWATER Depth to groundwater..1 41 feet method of determination or approximation: Installed s yt e m across the street water at 16, Water is 61 below cesspools . (revised 11/03/95) e W L ` Y V� I THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is. hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ' ion of Water Pollution Control --.r. tnr—r..•-�.--r.errr_'.r.:-:.--rre:.._........-r--.=-r.�c.--.-_ ........ ..... . 'TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION _ �!...�..;_T......--:.r••.--.r.--n•r.:—:—s.---.�e1.�..;_.:.----......... --.—r'-e.---�s-r—rr.=rr_—.srs��=r:.r.•r-rmrRrrrr.rr.-•.—rrr•r.._;.... A -TYPE OR PRINT CI,EARLY- PROPERTY INSPECTED STREET ADDRESS 711 Ynrmnut.h Rnna T-ynnni a'MaQa_ _n2h(11 ASSESSORS MAP, BLOCK AND PARCEL # • OWNER' s NAME T)r, T,_ VP.n6`7l --- — PART D - CERTIFICATION r NAME OF INSPECTOR joseth P. Macomber Jr,. COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 1790 - 1578 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 complete 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 : XXXXy= System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the 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 conducted has found that the system fails to Protect the Public ,health and the environment in accordance with Title 6 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . • 1 Inspector Signature Date _4/26/96 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF 11EAL'I'11. * If the inspection FAILED, this owner or " 'P' arator shall upgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CMR 15 . 305 . Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: 1411 fiZf_JV JA Ief BUSINESS LOCATION: INVENTO MAILING ADDRESS: T L AMOUI TELEPHONE NUMBER: CONTACT PERSON: ®hrI Tire o� EMERGENCY CONTACT TELEPHONE NUMBER: M— //,v - D,P MSDSDN SITE? TYPE OF BUSINESS: .Au zh2 �-e P__A r I ORMATION/RE,COMMENDATIONS: ��� Sf N D�npd; Fire District: S � s Waste Transportation: Last shipment of hazardous waste: 11-Gt' Name of Hauler: J't-!>V Destination: N&,) Waste Product: 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. UST 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 rlyle"AL 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 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, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers, I',,,� (including chloroform, formaldehyde, i Misc. Flammables �G(, 4 kw�^ 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 WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Town of Barnstable-Health Department Page 1 HAZARDOUS MATERIALS INVENTORY SITE VISITS i DBA: All Cape Auto Sales Fax: Corp Name: Mailing Address ........ .......... Location: 711 Yarmouth Road,Hyannis Street: 711 Yarmouth Road _ ..._.__..... mappar: City: Hyannis Contact: :John Trapp State: Ma Telephone: (508)775-0507 Zip: 02601 Emergency: (508)428-4408 Person Interviewed: Business Contact Letter Date: 12/8/2004 ....... Category: Miscellaneous Inventory Site Visit Date: 12/22/2004 Type: .Automobile Dealers Follow Up/Inspection Date: 0 public water ❑ indoor floor drains ❑ outdoor surface drains ❑ license required ❑ private water ❑ indoor holding tank mdc ❑ outdoor holding tank mdc ❑ currently licensed ❑ town sewage ❑ indoor catch basin/drywell ❑ outdoor catch basin/drywell expir -- - --- - W on-site sewage ❑ indoor on-site syste ❑ outdoor onsite system date: Notes: No toxic or haz.Mat.On site.6/25/97 12/22/04-alp-some haz mat compliance: on hand,stored in metal cabinet,interested in disposing of some Satisfactory enamel paints and unused product properly.MSDS must be obtained, fire extinguishers must be inspected. Page 2 Town of Barnstable-Health Department HAZARDOUS MATERIALS INVENTORY Chemicals: ❑ Zero Toxic Waste Materials W gty's>25 Ibs dry or 50 gals liquid but less than 111 gals ❑ gty's 111 gals or more "descr,�ptionof measure �. f - motor oil 1.5.gallons _.__._._........___......_.._......_._.__...._....................__.____.__..___........._..._.____..._......._......_......_...._.............................................._....._............_.._....__.._......_._._......._..__.._.._.._._..._.... paint,varnishes,stains,dyes I 2gallons antifreeze(for gasoline or coolant systems) 2gallons gasoline 0.25 gallons _... ._.........__ ......... .... _.... ..... ... ........ . ...... misc.petroleum products .grease,lubricants 1gallons --- car wash detergents 0.25gallons i i c.Flammable gallons Waste Transporter: :none Fire District: hyannis Last HW Shipment Date: Waste Hauler Licensed: No ......... ......... ......._. ............_..... Town of Barnstable-Health Department Page 1 HAZARDOUS MATERIALS INVENTORY SITE VISITS a DBA: All Cape Auto Sales Fax: Corp Name: Mailing Address Z: id Location: 711 Yarmouth Road,Hyannis Street: 711 Yarmouth Road _.... . .......... mappar: ! _City: Hyannis Contact: !John Trapp — State: Ma Telephone: (508)775-0507 Zip: 02601 Emergency: (508)428-4408 Person Interviewed: Business Contact Letter Date: s 67 Category: Miscellaneous Inventory Site Visit Date: a 0 Type: Automobile Dealers Follow Up/Inspection Date: 0 public water ❑ indoor floor drains ❑ outdoor surface drains ❑ license required ❑ private water ❑ indoor holding tank mdc ❑ outdoor holding tank mdc ❑ currently licensed ❑ town sewage ❑ indoor catch basin/drywell outdoor catch basin/drywell expir - ❑d on-site sewage ❑ indoor on-site syste ❑ outdoor onsite system date: Notes: No toxic or haz.mat.on site.6/25/97 compliance: rC not required aLvtf ' ash ` Ice oa( _ OBI f I�fBIv� V10 t 'Gam- S. iiGl V14 A5�1 1 1, �y� b o� Page 2 Town of Barnstable-Health Department HAZARDOUS MATERIALS INVENTORY Chemicals: ❑ Zero Toxic Waste Materials ❑ gty's>25 Ibs dry or 50 gals liquid but less than 111 gals ❑ gty's 111 gals or more Waste Transporter: Fire District: Last HW Shipment Date: Waste Hauler Licensed: No ........._ ......... .......................................... TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops unsatisfactory- 4.Manufacturers COMPANY (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS Class' 7.Miscellaneous UANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATE IALS C. se:10ts Above Tanksi IN OUT IN OUTI IN I OUT I#&gallons Age Test Fuels: Gasoline Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil(C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: DISPOSAIJRECI AMATION REMARKS: 1. Sanitary Sewage 2.Water Supply O Town Sewer ublic On-site OPrivate - 3. Indoor Floor Drains YES NO O Holding tank:MDC_ O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO ORDERS: O Holding tank:MDC O Catch basin/Dry well O On-site system 5.Waste Transporter r YES NO 2. s erviewed Inspector Date Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: �� C �z_ YqAcl BUSINESS LOCATION: al, A MAI LING ADDRESS:. Mail To: TELEPHONE NUMBER: —7 S Board of Health� � ��� © '7 Town of Barnstable CONTACTPERSON: P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: 02 �O Hyannis, MA 02601 TYPEOFBUSINESS: <,f; 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 a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site otherthan your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners 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 Rhotochemicals (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 Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS '10,:iv OF BARNSTAtsi,lr �j- us SEWAGE # ASSESSOR'S MAP&LOT u�STAJ.;.ER'S NAME&PHONE NO. SEYi'1C TANK CAPACITY AUB LEACHING FACILITY: (type)a°��i��P� C����J�v�(size) NO.OF BEDROOMS BUILDER OR OWNER �� . 4A0AAeZ1,4 PERMTTDATE: ^�� COMPLIANCE DATE: Separation Distance Between the: L Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands a 'st within 300 feet of-leachin ,f ¢'�'' ) �' Feet Furnished by r� � �{�6-25116 Nly p, i f