HomeMy WebLinkAbout7A STEVENS STREET - Health 7A Stevens
A=
Helping Hands
Y
E
0
t
s�
o
I
i
I,
i
i
I
i
I�
o
i
i
i
i',
Date: s p+ 98
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: [ eJ J
BUSINESS LOCATION:
MAILINGADDRESS: y-1 ' �- Mail To:
TELEPHONE NUMBER: P> ( r O
Board of Health_
�.
Town of Barnstable
CONTACTPERSON: v P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER: �� �`� -"���`F" Hyannis, MA 02601
TYPEOFBUSINESS:
Does your firm store ny of the toxic or hazardous materials listed below, either for sale or for you own
use? YES V 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
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
Paint brush cleaners (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
(dry cleaners)
t Other cleaning solvents
Bug and tar removers A-11-/
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
1
o �o
No.......�19... Fas., .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD . F HEALTH
.... ...........OF.......
. ►... ...................................................
Appliratinn -fur Bhipuiitt1 Works Tomitrnrtion Vrrniit
Application is hereby`made for a Permit to Construct ( ) or Repair (�dn Individual Sewage Disposal
System at:
C7"'• •• •. ..... ..�.'f.'..1.Y- -- �-- •--------------- •- -- e!2411,-----.--------•-••----••----•-----•-----------------•--------•---
Lo ion•'AUfress or Lot No.
• .... �- -= = --- -------------- ----------------•---------------------•------ -----...-----...------------------•--------•--....
Owner Address
--------•----------••---•-•----•---•--------
Installer Address
d ype of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms----------------------------------- --------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building .---_--------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
dOther 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 ( )
Percolation Test Results Performed by-......................................................................... Date....................................
a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................--- Depth to ground water........----------.-----
f4 Test Pit No. 2................minutes per inch Depth of Test Pit................---. Depth to ground water-_-----------------__-
O Description of Soil-------------------— A/---- --------- �---` ----- '� ? ....- ----� �--------- •
U ----------------------••-•----------------------------•••---•---•-•••----••--•----•---••-••-•••--------•-•••-•-•-•-•--••----••----------------------------------- - ------ - ----- - - ----- --
----------------- --•--• - ------------- ---------------------------
x - -- --- - - - --- - -----. . . - -- - j--�-- -�,........ . -ram
U Nature of Repairs or Alter ti s--A swer when a plica e.. .-.-.-.. .._
.---- -•- - ::::=
Agreement:
The undersigned agrees to install the afor Individual Sewage Disposal stem in accordance with
the provisions of Article XI of the State Sa ' ary Code The undersigned f r a not to place the system in
operation until a Certificate of Compliance e su d by the boar f a
Signed. .. = ----- .....`... ....... .........• ---- •-----------------------•----••-
Date
ApplicationApproved By--------------------------------------------------------------------------------------------- -- ----------------_---
Date
Application Disapproved for the following reasons-------------------------------------------------------- -- ---------------------------------------------------
••--.........••-••-•----•--••---•••••....................•-----•.•-••..---•-••••-•••••••••••••-•-••-•--••...----.---•-----•--------••-----------.•--•-•---------•---------•-•••------........---------••-
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
Application is hereby made for a Permit to Construct or Repair ( 41"'an Individual Sewage Disposal
System at:
Loc/fon-Address or Lot No.
Installer Address
Other Distribution box Dosing tank
----------------------_---- ------zk<_ V........... ------------------ --------- ---
en applica� t -
U _i�_-::AV;,
The undersigned agrees to install the afor Individual Sewage Disposal Sgstern in accordance with
the provisions of Article XI of the State Sa ry Code he undersigned f r a ot to place the system in
operation until a Certificate of Compliance su d by the boar f I
Date
Date
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTt
T911S IS D,0 GE IFY, Thal the PKdivitduer;ge Disposal System constructed or Repaired
V " A�
Iler
has been installed in accordance with the provisions of Article XI of Th State Sanitary Code as described in the
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSAUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
!�----- prV
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALT
Permission is hereby granted J,
to Construct or Repair S�n'�ividtial*','S'e'.'W"�"S'.'6----D-i's'posal �S-ys'te'* --------------------------------------------------------------------
Str et
as shown on the application for Di sal Works Construction P r No.. .......... Dated 7
Board_o_f_'H`ealth
DATE....... .........`----- ----- ..............................................
ronM /uss xoaosaWARREN. INC.. pvnus*snu
' -------^----'— ^
�.
;t
J
�` .
���
��
4
J �V
°av�� �`
��
�,�