HomeMy WebLinkAbout0345 FALMOUTH ROAD/RTE 28 - Health 34[__S FalmouthTRoad;Hyannis
A
Christy's Market
1
1
° r
TQWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,R pair
BOARD OF HEALTH z"V satisfactory 2.Printers
3.Auto Body Shops
unsatisfactory- 4.Manufacturers
COMPANY �` � O (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS Class: 7.Miscellaneous
QUANTITIES AND STORAGE (IN=indoors;OUT-outdoors)
MAJOR MATERIALS , ; .-.' :'
IN OUT IN OUT IN OUT #&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
t�
u;o w 44?j J,6
r-
Miscellaneous:
Alf
k1a
DISPOSALIRECLAMATION REMARKS:
1. Sanitary Sewage 2.Water Supply
dytown Sewer Opublic 1
O On-site OP64e IV
3. Indoor Floor Drains YES NO L
O Holding tank:MDC
O Catch basin/Dry well
O On-site system VINO_
4. Outdoor Surface drains:YES ORDERS:
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
5.Waste Transporter
YES NO
1.
2.
Person(s) Interviewed Inspector Date
J
Date: ¢ .
�"TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: }
BUSINESS LOCATION:
MAILINGADDRESS: ys Mail To:
TELEPHONE NUMBER:
Board of Health
S�d6• �� �� ��5' Town of Barnstable
CONTACTPERSON: P.O. Box 534
EMERGENCY CONTACT TEL PHONE NUMBER:�so�1S:q- �_� Hyannis, MA 02601
TYPEOFBUSINESS: f ., �:1� r .,.r• �� �
Does your firm store 50 of the toxic or hazardous materials listed below, either for sale or for you own
use? YES INO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your mailing
address:
ADDRESS: O
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 by ��- Quantity
3 Antifreeze(for gasoline or coolant systems) �_ Drain cleaners
✓NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator fl I shes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
a M oils ��a Pesticides
Moto
USED insecticides herbicides rodenticides
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil I 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
Y7 Car wash detergents Jewelry cleaners
1/_ Car waxes and polishes Leather dyes
Asphalt & roofing tar I Fertilizers
Paints, varnishes, stains, dyes PCB's
Lacquer thinners I Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
Paint brush cleaners I (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) I 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
a
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
j. BOARD OF HEALTHY satisfactory 2.Printers
3.Auto Body Shops
I O unsatisfactory- 4.Manufacturers
COMPANY l/�'�/S 13 (see"Orders") 5.Retail Stores
�j 6.Fuel Suppliers
ADDRESS 3 y ` I(7u'�t Class: 7•Miscellaneous
QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS Case lots 1rums Above Tanks .,LU,nderground Tanks
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline,Jet Fuel(A)
Diesel, Kerosene, #2 (B)
Heavy Oils:
waste motor oil(C)
new motor oil(C) a, X
transmission/hydraulic k
Synthetic Organics:
degreasers
/a'o1
SG/iGc�a e 114e )176,v)
Miscellanea .
y4- i
DISPOSAL/RECLAMATION' REMARKS:
1. Sanitary Sewage 2.WaterlSupply
WTown Sewer �Oublic
O On-site OPrivate
3. Indoor Floor Drains YES__ I NO X
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YES NO ORDERS:
O Holding tank: MDC
Catch basin/Dry well
O On-site system
5.Waste Transporter
Name of Hauler Destination Waste Product i'
YES N0
1.
2.
-2
'Person (s).Interviewed Inspector Date
010No.._�'.fe.347 �-iyannis, Massachusetts ®2 �°i Fws-20.....:..........
JHE COMMONWEALTH OF MASSACHUSETTS
BOARD Off` HEALTH
.. ..................OF. rn:y ab•..e,... -
Appilration for Mgpaa al Workri Tomitrurtio'n .rrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (*) an Individual Sewage Disposal
System at
3 5 / q(9......�i � f�
'.
-----------------
Location Address
e U �qs F&14a4.... .. .. .... .... . ._. i Do l
. a ................................
Owner .
a
re
Installer Addres
dType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p., Other—Type of Building No. of persons.................................... Showers ( ) — Cafeteria ( )
a' Other fixtures ------ --------------------- -
d
WDesign Flow..................................:.]--------gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid"capacity._..--.--.-gallons Length................ Width................ Diameter---------.-.-.-- Depth................
Disposal Trench—No. ................1... Width.................... Total Length.................... Total leaching area..............._____sq. ft.
Seepage Pit No--------------------- Diameter.--................. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Pe lformed'by---- -----------•--------------------••--•-----------...----------------- Date........................................
a Test Pit No. 1------------- minutes per inch Depth of Test Pit.................... Depth to ground water-.---------.-------.-__.
(X Test Pit No. 2.....:.::.......minutes per inch Depth of Test Pit..----.............. Depth to ground water------.---------.------.
04 ..............•------•-•----...--•---------•-•---•-•---------------------------•-----......-•---------•--...---•---------•----------------------------------
0 Description of Soil------------------------- ------------------•------•----------------•---•-•-----------------------------------------------------------------------•-----------------.
W -------------------------------- -- -- --•-----......------------------.
x -----•----- -------------------------------------------I-----------------=------------------------------------.....-•--------------------•---------------•---------------------------------...._------
V Nature of Repairs or Alterations—Answer when applicable.ZI --- ................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with "
the provisions of TuT.,r1 x
.a• 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board f health.
Signed.. t....V-& .....6-_ :.
Date
Application Approved By----.------ . ----- ...�.c _.._.__..... -------•--- -•---
Date
Application Disapproved for the f ollowing reasons--------------------------------------------------------•---------------------------------------•------..........
-----------------------------•-----•-•--...--------------.---•---•------...------..........-•---------••.---------------------•------------------------------------------------•---------------...------
Date
Permit No..... = •, ----------------------- Issued-._._......-••------
. Date------•---•---•---• .......
i
:....-............
T E COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l ._ OF....t-.........� . I _
Alip iration for UhipagFal Works Taaaitrurtivat runfit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
_? ?'i- �.;
........................................ -.......----........-i.................................. ........----------------••-----•-•-----• --- ------••---....._......_....----•.._.....•---
` �� Location-Addres rr // or Lot No.
� , her' , ("�=. 7/, �`.q fCi.t �.ci,i /.r,�..i ti
......
...............?.....`. ......_..._........._._..--................................... .......... ...............................................................Owner f Address
rl
---•----•--•---•....................................•----•-•------•-------_.....--•-••--•--.....;. ............................................
._..---------------------------
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building
yp g ........................... No. of persons........_................... Showers ( ) Cafeteria ( )
QOther fixtures •-----•--•-•......-••-----••---------------••••----•-•-••-••-•----•••-••-----•-•-••----•-•-•-•-•......---•-•......•..........
W Design Flow........................................_..gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity.......�____gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-----------_-------- Diameter----------------_-- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
"_4 Percolation Test Results Performed by.......................................................................... Date......................................
aTest Pit No. 1................minutlIes per inch Depth of Test Pit.................... Depth to ground water_---•-----_--.--------
Gi, Test Pit No. 2................niinuti s per inch Depth of Test Pit.................... Depth to ground water..----------------------
(� ---------
DDescription of Soil........................................................................................................................................................................
x
V •-•----•••••••••-••------••-••••----••...-•-•-------•----- ----------------------------------•----------•----•-•••-•--•-••-••-----------••--•---••---•----•••••....I.......---------•-..............
W ••-•••-----------------------•---•--•-----------•----------- -------•-------...------.........---•-------------.....----------------•------------------•-------------------------------------•-•-••--
V Nature of Repairs or Alterations--Answer when applicable.1_'.�~`R ...!°2� •/i/ �, �r. • i,
...... ----••.... ---••-----•-•-••-•----
••---•-----------•••••••-••••----•----•-------•------••---•-••••-••••-----••-••-•--.........•••••••-•--•-•----•--•-----•--------••-•----•-•--•••----•-•-----•-•••--•••••.............................
Agreement:
The undersigned agrees to i istall the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TILE
p5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
+-: ,F ( . -
Signed. •_--.• "-
Date
Application Approved BY ...................................... .......... -y' ��------
Date
Application Disapproved for the following reasons:..................................................................................................................
.................................................. ---------------------•-•-•-----••-------••---•--------------------••----•-• --•-•-----------••••--•--------•----•---•---••-••-•--••••..._.
pp Date
PermitNo....O - 7----------------------- Issued......-----•--------------------•---------- -------
Dste
5 HE COMMONWEALTH OF MASSACHUSETTS
`M'
L /. `�•!�
�' { BOARD OF HEALTH
I u f
Trrtif iratr of ToutpliFaatrr
THIS IS TO CERTIF , That the Individual Sewage Disposal System constructed ( ) or Repaired
by.................. ..L............... ......._...........---------------••••--•...-----........------•......------------•-•---•--•-----.....-•-------•••--------•--•--
M (��(QJ ,n Installer
has been installed in accordance with the provisions of TITitj of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._- f... ........ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.. C�---------•-•--•--.------ Inspector... .............................................................
�7 "614 1 HE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
•� ' .......... ory r, ................O F.. `' n.
oL{� L e
NO........ ............ FEE-.:.........--
�t���a�aal �rk� ��at,�tratrtirrat �erattit
Permission is hereby granted.......A-._.P......�r�
to Construct ( ) Re. it ) an ndivPua Sew ge Disposal System
at No. �� .
IJ Street Qgg�
as shown on the application for Disposal Works Construction Permit Noll.-,26 ... Dated..........................................
.................................
Board of Health
DATE............................---•----------------------------------•--
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
/ f~