HomeMy WebLinkAbout4738 FALMOUTH ROAD/RTE 28 - HAZMAT 2 �� o i c��—C�C7
f
Number Fee
1206 THE COMMONWEALTH OF MASSACHUSETTS $50.00
Town of Barnstable
Board of Health
This is to Certify that HALEEMA CORP. d/b/a SAMS FOOD
.--------------------------------------------------------------------------------------------------------------------------------
4738 Falmouth Road, Cotuit, MA
--------------------------------------------------------------------------------------------------------------------------------------------- ....------------
is Hereby Granted a License
For: Storing or Handling 26 - 110 gallons of Hazardous Materials.
------------- ------------------------------------------------------------------------------------------------------------------------------------------------------
Restrictions:
---------------------------------------------------------------- ...-------.
This license is granted in conformity with the Statutes and ordinances relating there to,
and expires 06/30/2021 unless sooner suspended or revoked.
---------------------------------------
JOHN NORMAN
DONALD A.GUADAGNOLI,M.D.
07/01/2020 PAUL J.CANNIFF,D.M.D.
THOMAS A.MCKEAN,R.S.,CHO
Director of Public Health
F , .
z
Town of Barnstable
Inspectional Services BARNSTABLE
Public Health Division •.TnB E• 16EtV-2014M•F[k,5
.AN.iS'.1Mic#1lS•OS.EM'VILL•t.?Si B?Rg51AE!E
639-2014
Thomas McKean, Director
e639. MA
n °'`� 200 Main Street, Hyannis,MA 02601
I�
Office: 508-862-4644 Fax: 508-790 6304
04
APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE
HAZARDOUS MATERIALS W
IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108,
HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS
GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS
JULY 1 st—JUNE 30th).
APPLICATION FEES 1 V
CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 R
CATEGORY-2 PERMIT l l l -499_Gallons: $125.00 El
CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ ;;-792-0
*A late charge of$10.00 will be assessed if payment is not received by July 1st.
1. ASSESSOR'S MAP AND PARCEL NO..
2. IS THIS A PERMIT RENEWAL?' ✓ YES NO. IF YES,SKIP QUESTION 3.
. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS
ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF
GREATER THAN HOUSEHOLD QUANTITIES(25 GALLONS)? YES NO.
4. FULL NAME OF APPLICANT:
5. NAME OF ESTABLISHMENT: A Jy)& rD W--VA-
6. ADDRESS OF ESTABLISHMENT: �}1 F '�
7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: w� -
8. TELEPHONE NUMBER OF ESTABLISHMENT: ti20 cS 3 6 -
9. EMAIL ADDRESS:
10. SOLEOWNER: VYES NO IF NO,NAME OF PARTNER:
11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF:
CORPORATION NAME e�iY��
PRESIDENT 10b
TREASURER
CLERK
12. IF PREPARED BY OUTSIDE PARTY:
NAME: TELEPHONE#:
COMPANY ADDRESS . EMAIL:
SIGNATURE OF APPLICANT DATE 12"
Q:Wpplication FormAHaz Mat Appli Draft Jan20l9.docx
Number
Fee
1205 THE COMMONWEALTH OF MASSACHUSETTS $50.00
Town of Barnstable
Board of Health
This is to Certify that HALEEMA CORP. d1b/a SAMS FOOD
4738 Falmouth Road, Cotuit, MA
Is Hereby Granted a License
For: Storing or Handling 26 - 110 gallons of Hazardous Materials.
This license is granted in conformity with the Statutes and ordinances relating there to,and
and expires 06/30/2020 unless sooner suspended or revoked.
---------- - --------------------------
PAUL J.CANNIFF,D.M.D,CHAIRMAN
DONALD A.GUADAGNOLI,M.D.
07/01/2019 JUNICHI SAWAYANAGI
THOMAS A.MCKEAN, R.S.,CHO
Director of Public Health
Town of Barnstable
�'THE Inspectional Services BABSTABLE
4—t 'Ci S 10.5 iS.VL'FC WiM HTAHkI_
• o Public Health Division YSTC`J ql.S JS EF17014vi&aaS
53 CO
1 LE. ' Thomas McKean, Director 0
039.
3.t A`0 200 Main Street, Hyannis,MA 02601
M.
Office: 508-862-4644 Fax: 508-790-6304
Shari
APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE '
HAZARDOUS MATERIALS
IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108,
HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS
GREATER THAN HOUSEHOLD QUANTITIES AREREQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS
JULY 1 st-JUNE 30th).
APPLICATION FEES
CATEGORY 1 PERMIT 26-.110 Gallons: $ 50.00 Q` VOT pl-I J,K.ar
CATEGORY 2 PERMIT 111 -499 Gallons: $125.00 ❑ 2060
CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑
*A late charge of$10.00 will be assessed if payment is not received by July 1st.
1. ASSESSOR'S MAP AND PARCEL NO. UO �
2. IS THIS A PERMIT RENEWAL?V/YES'_NO. IF YES, SKIP QUESTION 3.
3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS
• ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF
GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO.
4. FULL NAME OF APPLICANT: f&H.q % A)
5. NAME OF ESTABLISHMENT: <a,-e 1gre-A i
6. ADDRESS OF ESTABLISHMENT: S7G,�ry►a L�y'fit-� i�A �2
7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: ;' ---i-
a �
8. TELEPHONE NUMBER OF ESTABLISHMENT: 56_ ti2ro SS `L
9. EMAIL ADDRESS: 4 hV11-"-h44tZ,
10. SOLEOWNER: YES NO IF NO,NAME OF PARTNER:
11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF:
CORPORATION NAME VA-c�I evrn c, Ce %
PRESIDENT 1�,,YbcL/f K,. i �-
TREASURER
CLERK
12. IF PREPARED BY OUTSIDE PARTY:
NAME: TELEPHONE#:
• COMPANY ADDRESS EMAIL:
SIGNATURE OF APPLICANT - (h� i� DATE 2 D ` I
Q:\Application Forms\Haz Mat App Revised 09-10-18.docx
Number Fee
1205 THE COMMONWEALTH OF MASSACHUSETTS $5o.00
Town of Barnstable
Board of Health
This is to Certify that HALEEMA CORP. d/b/a SAMS FOOD
4738 Falmouth Road, Cotuit, MA
Is Hereby Granted a License
For: Storing or Handling 26 - 110 gallons of Hazardous Materials.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------
This license is granted in conformity with the Statutes and ordinances relating there to,and
and expires 06/30/2019 unless sooner suspended or revoked.
----------------------------------------
PAUL J.CANNIFF,D.M.D,CHAIRMAN
DONALD A.GUADAGNOLI,M.D.
07/01/2018 JUNICHI SAWAYANAGI
THOMAS A.MCKEAN,R.S.,CHO
Director of Public Health
�toewg8atory of BVnsxable
ervices
Richard V. Scah, Director "
j Public Health Division BARNSTABLE
sw.L
BRFNSTMLE•f&Rfl1VILLE•[QfUR•HVfJ.T115
BARNWABM Thomas McKeanMAE& , Director ��sN=-G R 4W5 BAFN5.4eE �
grE059-- 200 Main-Street, Hyannis-IVIA 02601----- ___..------------ �D�- ----- �--- -
r
a)
Office: 508-862-4644 Fax: 508-790-6304 w
APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE
HAZARDOUS MATERIALS :
IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108,
HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS
MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN
ANNUAL PERMIT(RUNS JULY 1 st-JUNE 3 Oth).
APPLICATION FEES
CATEGORY I PERMIT 26- 110 Gallons: $ 50.00g V.S .
CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 ❑
CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑
*A late charge of$10.00 will be assessed if payment is not received by July 1st.
1. ASSESSOR'S MAP AND PARCEL NO.
2. IS THIS A PERMIT RENEWAL? ✓YES_NO. IF YES, SHIP QUESTION 3.
3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS
ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF
• GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO.
4. FULL NAME OF APPLICANT: 1�Q y h a, a�-,;E
5. NAME OF ESTABLISHMENT: /0 co f � � 1 — �o 5a r')S �� 1Y)OW}--
6. ADDRESS OF ESTABLISHMENT: q-13 9 PU P0, i d 6
7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE:
8. TELEPHONE NUMBER OF ESTABLISHMENT: _ o .- 4 Zo 3 G 2 -
9. EMAIL ADDRESS: GTS� 'RG�/ heiai�- Co ni
10. SOLEOWNER: YES NO IF NO,NAME OF PARTNER:
11. FULL NAME,HOME ADDRESS,AND TELEPHONE# OF:
CORPORATION NAME
PRESIDENT
TREASURER
CLERK
12. IF PREPARED BY OUTSIDE PARTY:
NAME: TELEPHONE#:
COMPANY ADDRESS EMAIL:
SIGNATURE OF APPLICANT Egk-,,J' DATE_� — f
QAApplication Forms\HAZMAT APP 2017 REVISED. ocx
Number Fee
1205 THE COMMONWEALTH OF MASSACHUSETTS $5o.00
Town of Barnstable
Board of Health
This is to Certify that HALEEMA CORP. d/b/a SAMS FOOD
4738 Falmouth Road, Cotuit, MA
Is Hereby Granted a License
For: Storing or Handling 26 - 110 gallons of Hazardous Materials.
---------------------------------------------------------------------------------------------------------------- ---
This license is granted in conformity with the Statutes and ordinances relating there to, and
and expires 06/30/2018 unless sooner suspended or revoked.
---------------------------------------
PAUL J.CANNIFF,D.M.D,CHAIRMAN
DONALD A.GUADAGNOLI,M.D.
07/01/2017 JUNICHI SAWAYANAGI
THOMAS A.MCKEAN,R.S.,CHO
Director of Public Health
„y
ow of B nstable
-emu
egulatory ervices a
Richard V. Scali, Director
,THE Tp,. _
Public Health Division' BARNS'IBI,E
• ` ,. , - [M.kV5f ftlF{ lE0.VILLE COTUI N "I:
:. IAENSTABL , - naa>wshu csr av!LLt IWEsrac.r,.nEr
MASS. Thomas McKean, Director
s639• ,��.. ' �1 d
iOres639. 200 Main'Street, Hyannis,MA 02601 ,
m
6 C�v/
Office:`508-862-4644 '" � � Fax: 508-1-9076304
APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE
HAZARDOUS MATERIALS
Ln
IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL.ORDINANCE, CHAPTER 108,
HAZARDOUS MATERIALS, ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS
MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN
ANNUAL PERMIT(RUNS JULY 1st JUNE 3,0th).
APPLICATION FEES ,��L
CATEGORY 1 PERMIT 26- 110 Gallons: $ 50.00
CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 ❑
CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑
*A late charge of$10.00 will be assessed if payment is not received by July 1st.
1. ASSESSOR'S MAP AND PARCEL NO. 12
2. IS THIS A PERMIT RENEWAL? YES NO. IF YES, SKIP QUESTION 3.
3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS '
ZONING/BUILDING APPROVAL FOR'HAZARDOUS MATERIALS STORAGE/USE OF YF
GREATER THAN HOUSEHOLD,QUANTITIES(25 GALLONS)? YES NO.
4. FULL NAME OF APPLICANT r7c�'Y k,lc* '1
5. NAME OF ESTABLISHMENT: A
6. ADDRESS OF ESTABLISHMENT; �"1 �. '1: - ��l.tJ"1 n�—►� ,�5�
7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: — 1V
O. �/,—
11V�L HN1, INT 4�
iEL gnu � M ELIR �SYALL
9. EMAIL ADDRESS: . i / �� b + �., o Co v,,— -
10. SOLEOWNER: /YES NO IF NO,NAME OF PARTNER:
11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF:
CORPORATION NAMES G C' ,
PRESIDENT
TREASURER ,.�ti• ik _
CLERK
12. IF PREPARED BYOUTSIDE PARTY:
NAME: TELEPHONE#:
COMPANY ADDRESS EMAIL:
• SIGNATURE OF APPLICANT DATE
Q:\AppGcation FormsUTAZMAT APP 2017 REVISED.docx
• � !4
Number Fee 6
1205 THE COMMONWEALTH OF MASSACHUSETTS $so.00
Town of Barnstable
Board of Health
This is to. Certify that HALEEMA CORP. d✓b/a SAM'S FOOD
4738 Falmouth Road, Cotuit, MA
Is Hereby Granted a License
For: Storing or Handling 26 - 100 gallons of Hazardous Materials.
- ---- -------- - ----- -------- ----------------- ------ ------- -_------ --------- -------- --------- ------- --------` ------- -----------
This license is granted in conformity with the Statutes and ordinances relating there to, and
and expires 06/30/2016• unless sooner suspended or revoked.
----------------------------------------
WAYNE MILLER,M.D.,CHAIRMAN
PAUL J.CANNIFF,D.M.D.
02/29/2016 JUNICHI SAWAYANAGI
THOMAS A.MCKEAN,R.S.,CHO
Director of Public Health
Town of Barnstable
°Ft►�rqk, Regulatory Services
ti
Richard V. Scali, Director 44aa ahl
` BMWAB ' ` Public Health Division BARNSTABLE
s67.9. ��� -SONS Y:L$-WENSTA ",1 CWt BA STMU
A 16
39-2014 ^9
Thomas McKean, Director �Dg �..
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
N
N
APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE
HAZARDOUS MATERIALS
IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108,
HAZARDOUS MATERIALS, ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS
MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN
ANNUAL PERMIT(RUNS JULY 1st—JUNE 30th).
APPLICATION FEES
CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 -�I
CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 ❑
CATEGORY 3 PERMIT 500 or more Gallons: $150.00
A late charge of$10 00 will be assessed if payment is not received by July 1st.
• ASSESSORS MAP AND PARCEL NO. DATE o? l tY
FULL NAME OF APPLICANT: AAR14A%
NAME OF ESTABLISHMENT: hale-e- w761 610) d/h /I, So,V-n Is
ADDRESS OF ESTABLISHMENT: tf 13 � e �` fZ �c� ��/� �III�-� OZ
MAILING ADDRESS (IF DIFFERENT):
TELEPHONE NUMBER OF ESTABLISHMENT:
EMAIL ADDRESS:
SOLE OWNER: YES NO IF NO,NAME OF PARTNER.
FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: .
CORPORATION NAME w �
PRESIDENT �„���,¢ �A�E
TREASURER ,� A I w, C�
CLERK
IF PREPARED BY OUTSIDE PARTY:
SIG RE O APPLICANT Name:
Company Address
Telephone #:
Email:
Q:\Application Forms\HAZZAPP Revl6.docx Page I of 2
Town of Barnstable Office: 508-862-4644
Fax: 508-790-6304
Regulatory Services Department
• Public Health Division
s +
+"HARN3IA8G�
� Mom: Thomas A.McKean,CHO
1 Q` 200 Main Street, Hyannis,MA 02601
Payment Receipt
;Hazardous Materials Payment received: $50.00 (Check) on 2/29/2016
;Check number: 1844 Check amount: $50.00 Name on check: Haleema Corp
i
'Business: Haleema Corp DBA Sam's Food Owner: AALIYAH LLC
'Address: 4738 FALMOUTH ROAD/RTE 28, Cotuit
i
!Note:Note: Category I
i
I
•
K.ENYON OIL COMPANY, INC.
221 QUINEBAUG ROAD (RTE. 131
POST OFFICE BOX 866 -
NORTH GROSVENORDALE, CT 06255-086�:
ti
1998 Tier Two Emergency and Hazardous Chemical Inventory -DUE MARCH 1, 1999 %���� page 1 of '
Due to Electronic Processing Your form will be returned unless each item is completedl •`
68-0689 1-95 .�
Facility Identification(PLACE LABEL HERE CAUTION DO NOT OBSCURE YOUR PHONE t UMBER) Owner/Operator Name
Name SANTUIT XTRA MART 00137
Street_4738 FALMOUTH RD _ Name KENYON OIL COMPANY,INC. Phone_(860)935-5200_ a'
Sr
tr' �
City_COTUIT County BARNSTABLE State MA,Zip 02635,%__ Mail Address_P.O.BOX
Phone# _(508)420-5362 Latitude/Longitude City N.GROSVENORDALE State_ _Zip 0CT6255_
MUST HAVE Name KENYON OIL COMPANY,INC. Emergency Contact
Name JIM BLACK HELL Title_ENV CONTROL
YOUR MAILING ADDRESS Street P.O.BOX 866 I _ '
IF DIFFERENT FROM PO BOX City N.GROSVENORDALE State CT_Zip 06255-_ Phone_(860)935-5200 24 Hr.Phone_(860)935-5200
FA ILITY D AD—DRESS ATTN: JIM BLACKWELL i
Dun&Brad Name_ART HURLEY Title_R&M
SIC Code 5 5 4 1 Number 0 9 5 5 4 0 4 0 7 Phone_(860)935-5200 24 Hr.Phone_(860)935-5200� A
Physical Inventory Storage Codes STORAGE LSEE OOCATIONS
N PAGE 6
Chemical Description and Health SEE SEE
THE CHEMICAL NAME MUST BE IN i Hazards INSTRUCTION INSTRUCTION Oniv 106 characters available
ALPHABETICAL ORDER PLEASE SEE INSTRUCTION PAGE 3&a PAGE a including word spaces(Please Print)
PAGE 3
Container FACING PROPERTY TANKS ARE ON RIGHT SIDE OF
CHECK IF CHEMICAL INFORMATION IN THIS AREA IS IDENTICAL TO THE Type Pressure Temperature BUILDING
INFORMATION LISTED LAST YEAR. X Fire 1014
CAS 6 8 4 7 6 3 4 ® s�t E Sudden Release Max.Daily B 1 4
of Pressure Amount(fie)
Chem. Name DIESEL r�.� Reactivity 1014
+ X im ediate(acute Avg.
EHS Name 4 X Delayed(chronic) Amount(code)
Check all 3 6 5
that apply.' Pure MN Solid Liquid Gas EHS No.of Days
On-site da s
Container FACING PROPERTY TANKS ARE ON RIGHT SIDE OF
CHECK IF CHEMICAL INFORMATION IN THIS AREA IS IDENTICAL TO THE
Type Pressure Temperature BUILDING
❑INFORMATION LISTED LAST YEAR X Fire 0 5
CAS 8 0 0 6 6 1 0 Ts�ret C] Sudden Release Max.Daily B 1 4
of Pressure Amount(code)
Chem. Name GASOLINE Reactivity
XImmediate(acute Avg.Da y
EHS Name X Delayed(chronic) Amount(code)
6
Check am 3 fi 5s 5
that apply: Pure MX'tx Solid Liquid Gas EHS No.of oars
On-site da s
Ootional Attachments
Certification (Read and sign after completing all sections)7 ad I have attached a site plan
I certify under penalty of law that I have personally examined and am farnillar with the Information submitted In pages one thr gh 1 I have attached a list of site coordinate
on 1 fry of lndivl s r sponalble obtainln Information,I believe that the subndned Informatl a e, a r$te, ompl p� 1�(�� abbreviations
(O ana J I have attached a descriotion of
Name and official title of ownerlo rat s authori resentative nature Date alone ned �P'a� duties and other safeguard measures
�. .-.. Pay _�_ d ...1... naY•s
1 atrtt Approved OMO No 2050-0012 1
Rovised Juno 1990 ----------'-----
SANTUIT XTRA MART <Oygnert0 .. rator.Nama'
Friclll! Iden11f1ce,llori :` . ,.>:«.:>>:•;: _
. . :..:...Y ..:.:.{;.:.:::.:;: :<._: P�..;...{:. ......,. 974-1400 -
PO BOX 505 RTE 28 _ N KENYON OIL COMPANY INC Poe,,, 1203 ►: -
Ha� 4738 FAEMOUTH RD 221 QUINEBAUG RD,
Tier Two Stteei _ MatAddtosf N GROSVENORDALE CT 06255
EMERGENCY COTUIT MA . 02635
y ;.;::::<::::::<;.>:.::>;:::,.;•;:::;,:::.::;:>:>:.»:::::>:::>:: ;<:.::>:.: ::•::<;:::;;;>:::»::::.;.:.'. E N U I R 0 MENTAL"
AND Emer en Conlaflcl N
HAZARDOUS 1T .......
CHEMICAL SIC Code 5 9 9 5 Duna Bo ad 0 9 -. 5 5 4 - 0 4 0 7 Nanr JIM BLACKWELI Title CONTROL
INVENTORY I+�r (203' 974-1400
Phone (203 1974-1400 x�Hr.Pnotta
Speci�tc
Irtforrnafton ART HURLEY Title PERSONNEL DIR.
b CAerrucal
1
( )974-1400
��'���� :��• Phone (203 )974-1400 2�IIr.Pltons 2
Raaivad
Clack If tdcirr►ftkeT b�lnw»Idertlk�l b tM ntormahon
Important:Read all instructions before completing form Reporting Period From January 1 to oa�err�er�1,lg� ❑ ;Ubr„tl•d Ias1
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B 0 0 6 6 1 ❑9 Secret❑ Ar!!Ot{11;th0d l<>?`'`>><` `:? - �'--r
CAS�� Sudden Raise"
i
GASOLINE
d Presaun
Chem.Nerve A..ai+ty 04 .>:`A..Wit.`
,a,e,�y El El 3....6• 5 ::L?1ille(dltya) . ..pelayad(duortie)
Pure Mix Solid Liquid a" ENS :::>:r>:{;::; ;:::;.:r:;,:.•,;?.,•
ENS Nerve
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EHSName .:.s:;;;<,••:' '%z<.:A•x::,{.v:•:•:..•:,•::, :::.
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ENS Name
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tirl tic at n ..: (. a ,ta,,a .t.iar►g,/tltea , F ......:.N. . . ..... . .. ....
• 1 cvt/y urd.r penally o1 law that I have personally a.atrined and am l"liat with the inlormation submitted In pages one Ihiough• "• :.and that based1 My attached•fie gran
on my"uiry d Owea individuals responsbt.for obtaining the inlormalion,I believe that the subrtitted information is We•aetxttaie:and co e. 1 have attached a list d sie
w ✓ coordinate abbreviations
JIM BLACKWELL. ENVIRONMENTAL CONTROL A a�_ �'L ��� I have attached adextq.lionOf
r L.Nanr and oM-ci at title of ownerruper&tor on o«ned - g Dale signed dikes art)other f alrr)uard nwtaaures
opatald'f aurt•orised rgxesentalivs Sin e
+
NNE row� t f Town of Barnstable Office:508-862-4644
• °� I Public Health Division Fax:508-790-6304
• BARNSTABLE. '
9 MASS. ` 200 Main Street• Hyannis, MA 02601
s6y9. �0 1
MAy° 'TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT
C
Business Name: Ja s E-ooA C+� o ( 44 ,V Date: 10111 t `h
Location/Mailin Address: 4ISStea. w�.r�C• -4�.�
Contact Name/Phone: Si O 50K Ica l So - Tw- s
�( o a' ��w&-a. Sao--7977-343 x iz<-
Inventory Total Amount: SIDS: ►++� - k2 ba rs License#: IZ 5- Ce-+
Tier II : 0r,* , Labeling c , -, xw�Fa�-oK �/� g Spill Plan:�_
Oil/WaterSepia'
ep a'tor: A Floor Drains: 6 Emergency Numbers:
Storage Areas/Tanks:'J�%c7{•C
Emer enc /Containment E ui ment: -DJ-+ +y l( 6G•-� erc. S c k�
Waste Generator ID: A11A Waste roduct: f0o rv- V"Lfe� 2D tt,
Date&Amount of Last Shipment/Frequency: 'I I
Licensed Waste Hauler&Destination: RAV�e-.Q 1p
Other Waste Disposal Methods: cq—P wk
19>oo- 5pI -'TA/VK 7v yr
LIST OF TOXIC AND HAZARDOUS MATERIALS �• �a lG �.ti, L k 6G2 q
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons pr more requires
a,license from tl e Puk�liC ealth Pivis on.
/ p VAa +HIV ��J 3� q S ►hsi ,o0v
V+/ Antifreeze Dry cleaning fluids
Automatic transmission fluid Other cleaning solvents&spot removers
Engine and radiator flushes Bug and tar removers
Hydraulic fluid (including brake fluid) �— Windshield wash
Motor oils Miscellaneous Corrosives
Gasoline,jet fuel, aviation gas Cesspool cleaners
Diesel fuel, kerosene, #2 heating oil Disinfectants
Miscellaneous petroleum products: Road salts
grease, lubricants, gear oil Refrigerants
Degreasers for engines&garages Pesticides:
Caulk/Grout insecticides, herbicides, rodenticides
Battery acid (electrolyte)/batteries Photochemicals(Fixers)
Rustproofers Photochemicals(Developer)
Car wash detergents Printing ink
Car waxes and polishes Wood preservatives(creosote)
Asphalt&roofing tar Swimming pool chlorine
Paints, varnishes, stains, dyes Lye or caustic soda
Lacquer thinners V Miscellaneous Combustible
Paint&varnish removers, deglossers Leather dyes
Miscellaneous Flammables Fertilizers
Floor&furniture strippers PCB's
Metal polishes Other chlorinated hydrocarbons
Laundry soil &stain removers (including carbon tetrachloride)
(including bleach) Any other products with "poison labels"
(including chloroform,formaldehyde,
hydrochloric acid, other acids)
VIOLATIONS: IJo 5P+ll 9\010- ,Dos:a
ORDERS:
J � 1
INFORMATION/RECOMMENDATIONS: YJ0Aj0cg to
Inspector:-
Facility Representative: /IVI
WHITE COPY- HEALTH DEPARTMENT/CANARY COPY- BUSINESS
IKE 1ok4 Town of Barnstable Office:508-862-4644
Public Health Division Fax:508-790-6304
• RnRMASSBLE.�` 200 Main Street• Hyannis, MA 02601
�A 1639• �0
'Foy" TOXIC AND HAZARDOUS MATERIALSINSPECTION REPORT
Business Name: S�,.vw s oo v 11 0 I`ta�P�2wut Cow Date: 1 27 1-7
Location/Mailing Address: 14'738 C.+,,}-
Contact Name/Phone: -� ►ga W� /soy- � �� So9 -�,120-S3�Z 4 's d corm<52r.,
`Ja`ft4 � S&o-8=ss
InventoryTotal Amount: �. �� MSDS: O.VAA -c -C��da5) License#: I zas 6%+ % 3y3q
Tier II : o Labelina: (-c'haL. Spill Plan: Mb )d 125'
Oil/WaterSeparator: Floor Drains: N�o Emergency Numbers: n
Storage Areas/Tanks: 3- 10 V QD I cA
,A a 5 o(-A vAA-
Emer enc /Containment E ui ment: �c 4,xk-, vA$Vv,s V,�-
Waste Generator ID: Waste Product: Ot i v wkke.
Date&Amount of Last Shipment/Frequency:
Licensed Waste Hauler&Destination:
Other Waste Disposal Methods:
LIST OF TOXIC AND HAZARDOUS MATERIALS C I.A. S 1wc e (e �--, -
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws 0f K�IA, hazardous materialf use, k%A' i ovL
storage and disposal of 111 gallons or more requires a license from the Public Health Division.
Antifreeze Dry cleaning fluids
V Automatic transmission fluid Other cleaning solvents&spot removers
Engine and radiator flushes Bug and tar removers
Hydraulic fluid (including brake fluid) Windshield wash
Motor oils Miscellaneous Corrosives
Gasoline,jet fuel, aviation gas Cesspool cleaners
Diesel fuel, kerosene, #2 heating oil Disinfectants
Miscellaneous petroleum products: Road salts
grease, lubricants, gear oil Refrigerants
Degreasers for engines&garages Pesticides:
Caulk/Grout insecticides, herbicides, rodenticides
Battery acid (electrolyte)/batteries Photochemicals(Fixers)
Rustproofers Photochemicals(Developer)
Car wash detergents Printing ink
Car waxes and polishes Wood preservatives(creosote)
Asphalt&roofing tar Swimming pool chlorine
Paints, varnishes, stains, dyes Lye or caustic soda
Lacquer thinners Miscellaneous Combustible
Paint&varnish removers, deglossers Leather dyes
�- Miscellaneous Flammables Fertilizers
Floor&furniture strippers PCB's
Metal polishes Other chlorinated hydrocarbons
yLaundry soil &stain removers (including carbon tetrachloride)
(including bleach) Any other products with "poison labels"
(including chloroform,formaldehyde,
�(( ,gg�� i, 11 1 hydrochloric acid, other acids)
VIOLATIONS: N o r-�15�5 ovL S i�2. Na 5���l Phan, �a sty; • tVv Wk,S�e Mctvi��25�5
ORDERS: C4.; 0-0 «S a q—AX- 5 \A) oK. % e—. OS
INFORMATION/RECOMMENDATIONS: Mtn �avt,S awVtS a5G - wc. e� u GG Inspector:-<
7 W�p �.�Q %\AAf LL C•• , Facility Representative:
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
�p�'i•�1�d `�GQ.wbyl� tL3 L4"(41 Do,?)ILA(0
IKErp�4 Town of Barnstable Office:508-862-4644
Public Health Division Fax:508-790-6304
B,RNSTABLE.
MAss. g 200 Main Street• Hyannis, MA 02601
Fo�'A9. TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT
Business Name: Sawt 5 roc ,10"cV fQS Date: / I
Location/Mailing Address: P,. k o,+
Contact Name/Phone: _5Z S(S
W\ v,,.M&a�-. gv`n- 4" cove. 3ara
Inventory Total Amount: ti 6L MSDS: o License#:--16�> C&++
Tier II : Labeling: CeA'kk Spill Plan:
Oil/WaterSeparator: N 10, Floor Drains: d1P Emergency Numbers:
Storage Areas/Tanks: tb 0vi7 a,1 Q 4,12 ml vtA--
Emergency/ContainmentE ui ment: .i !_,Ck% +� 4 S�r��r� t�
Waste Generator ID: Q114 Waste Product:
Date&Amount of Last Shi ment/Fre uenc :
Licensed Waste Hauler&Destination: 1
Other Waste Disposal Methods: k S aver Jv1 k;< t-)
LIST OF TOXIC AND HAZARDOU MATERIALS
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 requires a license from the Public Health Division.
Antifreeze 16 Dry cleaning fluids
Automatic transmission fluid 4 Other cleaning solvents&spot removers
Engine and radiator flushes Bug and tar removers
Hydraulic fluid (including brake fluid) Windshield wash
Motor oils yo+Z Miscellaneous Corrosives
Gasoline,jet fuel, aviation gas Cesspool cleaners
Diesel fuel, kerosene, #2 heating oil Disinfectants
Miscellaneous petroleum products: Road salts
grease, lubricants, gear oil Refrigerants
Degreasers for engines&garages Pesticides:
Caulk/Grout insecticides, herbicides, rodenticides
Battery acid (electrolyte)/batteries Photochemicals(Fixers)
Rustproofers Photochemicals(Developer)
Car wash detergents Printing ink
Car waxes and polishes Wood preservatives(creosote)
Asphalt&roofing tar Swimming pool chlorine
Paints, varnishes, stains, dyes Lye or caustic soda
Lacquer thinners Miscellaneous Combustible
Paint&varnish removers, deglossers Leather dyes
Miscellaneous Flammables I- Fertilizers
Floor&furniture strippers PCB's
Metal polishes Other chlorinated hydrocarbons
Laundry soil &stain removers ti (including carbon tetrachloride)
(including bleach) I Any other products with "poison labels"
(including chloroform, formaldehyde,
, \ hydrochloric acid, other acids)
VIOLATIONS:A n�O v � 51?6 ®VL --�lip— o ,SD� �� ,Qtal-
ORDERS: V4 Gl 5 D S
I FORMATI N/RECOMMENDATIONS- - QA oc�, a v� 14 -
c— 2. IIL .
0 I t �P N(t Q 1 �; a UJ' ector:co 6LA- C�
U01 � Facility Representative:
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
°p IKE*ok� Town of Barnstable Office:508-862-4644
Public Health Division Fax:508-790-6304
"M�`E'g 200 Main Street• Hyannis, MA 02601
MA+&`� TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT
Business Name: -5 y%l/S �De�Q �,JvLoCo a3 --7�4-.CA, Date:
Location/Mailing Address: y-73e) �Q� Cd*V1
Contact Name/Phone: ASi a 04- O - '-l20-S,.�j
Inventory Total Amount: --b MSDS: o License#:
Tier II : No Labeling: ceAeO Spill Plan:
Oil/WaterSeparator: Floor Drains: n�o Emergency Numbers: 11 q,�.s l00�1
Storage Areas/Tanks: Oo e,1 s - v 1 I V-R,
Emergency/Containment Equipment: 20�� < va�lA Ie, 0 6�ta1 S S
Waste Generator ID: - -kd# g1 is N Waste Product:
Date&Amount of Last S�, Ament/Frequency:
Licensed Waste Hauler&Destination:
Other Waste Disposal Methods:
LIST OF TOXIC AND HAZARDOUS MATERIALS
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 requires a license from the Public Health Division.
10 Antifreeze Dry cleaning fluids
Automatic transmission fluid Other cleaning solvents&spot removers
Engine and radiator flushes Bug and tar removers
Hydraulic fluid (including brake fluid) Windshield wash
Motor oils Miscellaneous Corrosives
Gasoline,jet fuel, aviation gas Cesspool cleaners
Diesel fuel, kerosene, #2 heating oil Disinfectants
Miscellaneous petroleum products: Road salts
grease, lubricants, gear oil Refrigerants
Degreasers for engines&garages Pesticides:
Caulk/Grout insecticides, herbicides, rodenticides
Battery acid (electrolyte)/batteries Photochemicals(Fixers)
Rustproofers Photochemicals(Developer)
Car wash detergents Printing ink
Car waxes and polishes Wood preservatives(creosote)
Asphalt&roofing tar Swimming pool chlorine
Paints, varnishes, stains, dyes Lye or caustic soda
Lacquer thinners _� Miscellaneous Combustible
Paint&varnish removers, deglossers Leather dyes
Miscellaneous Flammables Fertilizers
Floor&furniture strippers PCB's
Metal polishes Other chlorinated hydrocarbons
Laundry soil &stain removers (including carbon tetrachloride)
(including bleach) Any other products with "poison labels"
(including chloroform, formaldehyde,
hydrochloric acid, other acids)
VIOLATIONS:_ 0.0 6L-J&A&w4-,
ORDERS:
INFORMATION/RECOMMENDATIONS: CD0 c AK 0 -Si Z, avvts
0 '��M
1 Facility Representative:
yy
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
ly
TOWN OF BARNSTABLE Date:3 /!8 /
V1 a���K�
TOXIC AND HAZARDOUS MATERIALS FORM
NAME OF BUSINESS: svv`oc o ��A �g �o,74)
BUSINESS LOCATION: 4-IS?) C*4"+ INVENTORY
MAILING ADDRESS: TOTAL AMOUNT:
TELEPHONE NUMBER: !moo o 'L[S0 --S'3soI-
Ill q� l
CONTACT PERSON: AS,� Ba.-I vok
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS: 949 5 love Covoevit4-Atz 60
INFORMATION / REC 00 MENDA�TI ppNS: o-e Fire District:
JSk �- vc BG ►o l-7o D�.`s oSa� Q c. n o l Cd k
Uc -k'o A9A6 s O'k v- vt--,oZae c s
Wru� �o5�,e y
Waste Transportation: +0 CtteA-c w'aQ�9{-c,c� Last shipment of hazardous waste:
Name of Hauler: vv�c�W ,! Q- Q5 Wa Destination:
Waste Product: Y1111, D&Kot- VWA- alccvvJ+t�6Licensed? 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
to__ An ' reeze (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
2(p Motor Oils Pesticides
Q 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,
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
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials to