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TOXIC AND HAZARDOUS ATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS:: XIVtiV del Board of Health
MAILING ADDRESS: 02e) 6,tei--Z OA) �5 f dWzF_L 11c5 , 4 6V60/ Town of Barnstable
TELEPHONE NUMBER: '77,5- O6(7_ P.O. Box 534
CONTACT PERSON: _af xb2,4s/ .&�25 Hyannis, MA 02601
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalling, at any time, more than 50 gallonsliquid volume or 25 pounds dry
weight? 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 other than 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
characteristics and must be registered
vo s, ut a check beside each product that you store:
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid X Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) Disinfectants
Motor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
Paints, varnishes, stains, dyes Fertilizers (if stored outdoors)
Paint & lacquer thinners PCB's
Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
C Metal polishes (including chloroform, formaldehyde,
Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy-Health Department/ Canary Copy-Business
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