HomeMy WebLinkAbout0051 MAIN STREET (HYANNIS) - Health 51 Main Street, Hy '
Q
BI012AN ME
i
.,a
COMMONWEALTH OF NLaSSACHUSETTS
jo EXECUTIVE OFFICE OF EN-VIRONMENTAL AF FS
b` DEPARTMENT OF ENVIRONMENTAL PROTE LION ',
ONE CCI\TER STREET. BOSTO\ �L� 021UE 1615J 292•aipt .
O
1999 N i
TRU O\
Q'T can
TP.::I;S
ARGEO PALL CELLUCCI y
mmiss::,-.e:
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
d A&A PART A
��"tjG��� CERTIFICATION
��Address: 50 (}•kA kav '�t L _ Name of Owner
��!!tt W E}r1 �L;rS(�G�` Address of Owner: 3( �+is .r Z-
Date of Inspeetion:..�pl i\rl� //1 / G� / S
Name of Inspector:(Please Print) a a_�_,%��J ELK U
I am a DEP approved system inspector pursuant to Section 15.[[340 of Title 5(310 CMR 15.0001
Company Name. ,87Yus lr't
Mailing Address:? Z_-1
Telephone Number: / So _ ( 3 Z 4- • ZG
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By Local Approving Authority
_ Fails
Inspector's Signature:
Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEPlwithin 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.
NOTES AND COMMENTS
revised 9/2/98 pale'Iof11
� Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
�J *roperty Address: g Lem
Jwner`3- 1.;''
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES: °
�♦ f
• I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N. or ND). Describe basis of determination in all instances. If "not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
b
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced _..
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
Inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
Page 2 of It
revised 9/2/98
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to deter ne if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE TH 310 CMR 15.303(1)(b)THAT.THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PU LIC WATER SUPPLIER, IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC LTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption s stem(SAS) and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorptio system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorpti system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil .bsorpti n system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well wate analysis for eoliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine dis once (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as descr ed in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to det rmine what will be necessary to correct the failure.
Yes No
_ Backup of sewage into facility or system component due to an overl aded or clogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground ors rface waters due to an overloaded or clogged SAS or
cesspool.
_ Static liquid level in the distribution box above outlet invert d e to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6" below invert or av able volume is less than 1l2 day flow.
Required pumping more than 4 times in the last year N due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspoo or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 f et of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a ne I of a public well.
_ Any portion of a cesspool or privy is within 0 feet of a private water supply well.
Any portion of a cesspool or privy is less- an 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the ell has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic comp unds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of th following:
The following criteria apply to large system in addition to the criteria above:
The system serves a facility with a desig flow of 10.000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment b cause one or more of the following conditions exist:
Yes No
the system is within 400 f t of a surface drinking water supply
the system is within 200 eet of a tributary to a surface drinking water supply
the system is located I a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a public
water supply well)
The owner or operator of any such sys m shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further in armation.
revised 9/2/98 p�Re�ertl
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
NoPumping information was provided by the owner, occupant, or Board of Health.
None 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.
As built plans have been obtained and examined. Note if they are not available with N.A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
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.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(15.302(3)(b)1
The facility owner (and occupants.if different from owner) were provided with information on the propermaintenan"-of
Subsurface Disposal Systems.
revised 9/2/98 Page cofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SC ( p SYSTEM INFORMATION
'roperty Address:9S L�4 N �I w
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: Q g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual): c'��
Total DESIGN flow 7%75O
Number of current residents: (�3
Garbage grinder(yes or no): ti
Laundry(separate system) (yes orQ_--: If yes, separate inspection required
Laundry system inspected es r no)
Seasonal use (yes c nol:
Water meter readings, if available (last two year's usage (gpd): fQ
Sump Pump(yes or no):
Last date of occupancy:`
COMMERCIALfINDUSTRIAL:
Type of establishment:
Design flow: qPd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informatio
System pumped as part of inspection: (yes or no)_L-<-::i
If yes, volume pumped: gallons
Reason for pumping:
TYP OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous Inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
X N
APPROXIMATE AGE of all components, date Installed(if known) and source of information:
Sewage odors detected when arriving at the site:(yes or no) PAD
revised 9/2/98 Page 6(if 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: L—,
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
it
Depth below grade:
Material of construction: _cast iron 440 PVC_other (explain)
Distance from piivate water supply well or suction line
Diameter k
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:,Q)
(locate on site plan)
Depth below grader
Material of construction: 1concrele metal _Fiberglass _,Polyethylene —other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_ (Yes/No)
Dimensions: OUC�i� l
Sludge depth: 1.1
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:11
i
Distance from top of scum to top of outlet tee or baffle: h ,i
Distance from bottom of scum to bottom of outlet tee or baffle:_
How dimensions were determined: q\A .QC?�\
'omments:
n of inlet and outlet tees�or baffles, depth of liquid leveE S rel`t n to outlet invert. stru`.cttur integrity
(recommendation for pumping, conditio .
evidence of leakage,etc.) v
w T
GREASE TRAP:,��P
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of Inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Psge7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: I (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal_Fiberglass _Polyethylene—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order: Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:�n
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:(no if ley.�l and distributio 's equal, evidence of solids carryover ev' en'e of I kage into or o t of box, etc.) -
y L
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,•condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
I
Y AtiVoperty Address: S Lr
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):4-S
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:IL41, f
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of so,,i, signs of hydraulic failure, level of onding, damp soil, condi 'on of vegetation, tc.I -�
S� F
tj
CESSPOOLS: WO
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9orII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'Iroperty Address: V-A41 Kj
)wner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
Z
3 �
53
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address: SO �t{b(1 fU S LL
Owner:
Date of Inspection:
NRCS Report name - --- ------- --
Soil Type_ _ --------- ------
Typical depth to groundwater_
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate —Deep________
SITE EXAM Slope jjo -
Surface waterlJ—"-*'
Check Cellar 01(c
Shallow wells
Estimated Depth to GroundwaterL JFeet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property. observation hole. basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators. installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
U
revised 9/2/98 page iiorli
I
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS: r i Board of Health
MAILING ADDRESS: KQ1 il� 5-V, Town of Barnstable
TELEPHONE NUMBER:_ 17 I- �CO U ' P.O. Box 534
CONTACT PERSON:
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 total 'ng, at any time, more than 50 gallons liquid 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
f"P`lease put a check beside each product that you store:
Antifreeze 9 for asoline.or coolants systems)Y ) Drain cleaners
Automatic transmission fluid 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
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 �'�•�
TOXIC AND HAZARDOUS MATERIALS REGIS ATION FORM
NAME OF BUSINESS /�U/� 442 /Wd �G Mail To:
y y Board of Health
MAILING ADDRESS: 5'11 MOW SJ M4,i�Wl Town of Barnstable
TELEPHONE NUMBER:S-2�v f-?7 l —"? P.O. Box 534
CONTACT PERSON: 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 gallons liquid 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
Please put a check beside each product that you store:
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid 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
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
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: Mail To:
BUSINESS LOCATION: WILLIAM J. MANNING, JR., M.D. Board of Health
5 rMA1N 8T-.
MAILING ADDRESS: HYANNIS, MA 02601 Town of Barnstable
P.O. Box 534
TELEPHONE NUMBER: Hyannis, MA 02601
CONTACT PERSON:
EMERGENCY CONTACT TELEPHONE NUMBER:
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 gallons liquid 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 character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid 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 �o9p- rodenticides)
Degreasers for engines and metal X'46r Photochemicals C(fixers)and=developers'
Degreasers for driveways & garages j 0 'k . 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
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
TOXIC AND HAZARDOUS MATERIALS REGISTR TION FORM
NAME OF BUSINESS: CA-PF COT) Q&jfPTk J U46f',Q Y Mail To:
BUSINESS LOCATION: Sf .inj .el- /4 A/ VAII. A Board of Health
MAILING ADDRESS: S ,u, 0 Town of Barnstable
P.O. Box 534
TELEPHONE NUMBER: �7 71 0 2- S 0 Hyannis, MA 02601
CONTACT PERSON: Z_ Uye NL F 14 HC- J�4U a /UI
EMERGENCY CONTACT TELEPHONE NUMBER:
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalli , at any time, more than 50 gallons liquid 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 character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid 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
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
I Household cleansers, oven cleaners
White Copy- Health Department/ Canary Copy-Business
r
e000001
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: Cape Cod Eye Consultants Mail To:
BUSINESS LOCATION: 51 MAIN ST. Board of Health
Town of Barnstable
MAILING ADDRESS: 51 Main st. Hyannis P.O. Box 534
TELEPHONE NUMBER: 771-6447 Hyannis, MA 02601
CONTACT PERSON: Dale C. oates, MD
EMERGENCY CONTACT TELEPHONE NUMBER:
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities �.
totallin any time, more than 5 gallons liquid 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 character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid 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
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
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
BOARD OF HEALTH satisfactory 2.Printers
3.Auto Body Shops
/� O unsatisfactory- 4.Manufacturers
COMPANY I 1 efit (see"Orders") 5.Retail Stores
�p(�` 6.Fuel Suppliers
ADDRESS ti;lg55: 7.Miscellaneous
QU TITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALSUnderground 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)
transmission/hydraulic
Synthetic Organics:
degreasers
Miscellaneous:
. 6
�50 Y
DISPOSAIJRECLAMATION REMARKS:
f.
1. Sanitary Sewage 2. Water Supply -
`Town Sewer ublic
On-site rI
3. Indoor Floor Drains YES N0
4 01 Uo
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YES NO O RS:
O Holding tank:MDC J ��
O Catch basin/Dry well Srn ALL4
O On-site system Q
5.Waste Transporter
Name of Hauler Destination Waste Product
1.
2.
—I— � v
Person (s) Interviewe Inspec or at
i
Ve4000,*,
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS: Bioran Medical Laboratory Board of Health
MAILING ADDRESS: 415 Mass .. Ave . Cambridge , MA 02139 Town of Barnstable
TELEPHONE NUMBER: 617-547-8900 P.O. Box 534
CONTACT PERSON: T• Licausi 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 gallons liquid volume or 25 pounds dry
weight? YES NO x
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 id
oaur - 02 c Please put a check beside each product that you store:
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid 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 10 cal 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 less, 1 gal Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
2galsL.aundry 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