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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: q j S Aj7d A if 71 u E
BUSINESS LOCATION. 49 )0001)1 SA
MAILING ADDRESS:_ - _� /Vo r/� Mail To:
TELEPHONE NUMBER:
Board of Health
S- � _ /��� Town of Barnstable
CONTACT PERSON: C i h c%1 Ya r� P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER: 7 1 1" V Y0 I Hyannis, MA 02601
TYPEOFBUSINESS: Ai a, I Se-ryrc c S . h
Does your firm store a_Y of the toxic or hazardous materials listed below, either for sale or for you own
use? YES i/ 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
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
Lacque thinners Other chlorinated hydrocarbons,
V NEW USED inc. carbon
Paint & varnish removers, deglossers ( tetrachloride)
—�. Any other products with "poison" labels
Paint brush cleaners
(including chlorofor , formaldehyde
Floor& furniture strippers hydrochloric acid, other aci
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
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
-7
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TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory
BOARD OF HEALTH 2.Printers3.Auto Body Shops
r O unsatisfactory- 4.Manufacturers
COMPANY !( � (see"Orders") 5.Retail Stores
.- 6.Fuel Suppliers
ADDRESS �' l < Class: 7.Miscellaneous
1V'tV'4teZMUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS Case lots Drums
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline,Jet Fuel (A)
^ten01�r
Diesel, Kerosene r#2B)
Heavy Oils:
waste motor oil (C)
new motor oil(C)
transmission/hydraulic
Synthetic Organics:
degreasers
Miscellaneous:
Pte �
SA
t. O
V� ,..
DISPOSAL/RECLAMATION REMARKS:
1. anitary Sewage 2.Water Supply ' 1(4
Town Sewer *ublic
0 On-site OPrivate
3. Indoor Floor Drains YES N0,-�
O Holding tank:MDC
0 Catch basin/Dry well
0 On-site system
4. Outdoor Surface drains:YESYNO ORDERS:
0 Holding tank:MDC
XCatch basin/Dry well " ^`
0 On-site system
5.Waste Transporter
Name of Hauler Destination Waste ' 6d
YES NO
2.
Person(s) Interviewed Inspector Date
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: CrcQ �ive n Mail To:
BUSINESS LOCATION: r Board of Health
MAILING ADDRESS: 5(/1mP Town of Barnstable
P.O. Box 534
TELEPHONE NUMBER: Hyannis, MA 02601
CONTACT PERSON: mutacCIQ
EMERGENCY CONTACT TELEPHONE NUMBER: 1
61 ,71575 ' 144
Does your firm st a any of the toxic or hazardous materials listed below, either for sale or for
your own use, in qua ies total at any time, more than 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 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 a r, l Isb ' Emavet-
Bug and tar removers ACC f oe , oon Oceione
Household cleansers, oven cleaners —� nC r l y icj ' )wACf
White Copy-Health Department/ Canary Copy-Business