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Date: TA
TOXIC AND HAZARDOUS MATERIA S REGISTRATION FORM
NAMEOFBUSINESS: S �G\ 13
BUSINESS LOCATION:
MAILINGADDRESS: 13 01 Mail To:
TELEPHONE NUMBER: Board of HealthTown of Barnstable
CONTACT PERSON: L i)Cb IJ P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER: �'2.Q�e�1�5q Hyannis, MA 02601
TYPEOFBUSINESS: ct\r *:� \
Does your firm store ny 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 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 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 `Z
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides
NEW 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 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
Paint brush cleaners Any other products with "poison" labels
(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 3
/ (dry cleaners)
v Other cleaning solvents zo
- Bug and tar removers
o Quo
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body Shops
O unsatisfactory- 4.Manufacturers
Ati-:14/4 (see"Orders") 5.Retail Stores
COMPANY6.Fuel Suppliers
ADDRESS CIP rv&-L .) Class: 7> 1
7.Miscellaneous
QUANTITIES AND STORAGE (IN= indoors;OUT=outdoors),
MAJOR MATERIALS dase lots, Dr Underground T.Z''Ab inks
IN OUT IN OUTI IN 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:
Ix-
DISPOSAUR.ECLAMATION REMARKS:
1. Sanitary Sewage 2. �,j�er Supply Lf
Town Sewer Ovblic o2 K-4-4— .
O On-site OPrivate
3. Indoor Floor Drains YES N0k—
O Holding tank:MDC
0 Catch basin/Dry well
0 On-site system
4. Outdoor Surface drains:YES _NO OR ERS:
0 Holding tank:MDC
Catch basin/Dry well
O On-site system
5.Waste Transporter
Name of Hauler Destination
YES NO
1.
2.
rson (s) Interviewed Inspector Date