HomeMy WebLinkAbout187B WEST MAIN STREET - Health BTB--VVest Main Street, yannis
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TOWN OF BARNSTABLE OMPLJANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body shops
�e /� ® unsatisfactory- 4.Manufacturers
COMPANY �� (� (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS @Anko Class: 7.Miscellaneous
QUANTITIES AND 9TORAGE (IN=indoors;OUT=outdoors)
MAJOR MATER S Case lots Drums Above Tanks Underground 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
Miscell;76vow
DISPOSAL/RECLAMATION REMARKS:
1 ariitary Sewage 2. Y ater Supply 'q®qO&W-t, %L .
Town Sewer Public - e nz UVAro 11z&ff
On-site fOPrivate
3. Indoor Floor Drains YES NO.-
O Holding tank:MDC
O Catch basin/Dry well
O On-site system 95aALLOAPSC o
4. Outdoor Surface drains:YES NO Off: ®• � 0PA" op4w f
O Holding tank:MDC
O Catch basin/Dry well flu (9T) VWxLL1\.S
O On-site system
5.Waste Transporter
Name of Hauler Destination Waste Product
1. r o f O, I YES NO
2. 1�.r �/
Person (s) Inte wed Inspect at�05
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: PRIG S T 0 V:,Z-�'0 Mail To:
BUSINESS LOCATION: C3 Vi k,�-': ITI q) N S; Board of Health
Town of Barnstable
MAILING ADDRESS: I �6� S-C � ��N v� P.O. Box 534
TELEPHONE NUMBER: Hyannis, MA 02601
CONTACT PERSON: d,�J l L
EMERGENCY CONTACT TELEPHONE NUMBER: I "1'Qi
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in antities 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 rodenticides)
Degreasers for engines and metal o 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
CO.MMONWEAI TH OF MASSACHUSiTTc l � A j�Ki
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DEPARTMENT OF ENVIRONMENTAL PROTECTION; ' ,
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DIVISION 'OF HAZARDOUS WASTE / / a" F ;«`
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One Winter Street Boston, Massachusetts 021�08 ,
r Please print or,type (�orm deslgned`for'L§e�bn ellte�(12 pitch)tyf3e¢ Ite ) a
Y Generator's US EPA ID No Zmanl(Asl:Document:No k t� or
UNIFORM HAZARDOUS 2 , PAge 1 �, lnforrrtahon In the shaded,aie�s ;
not'requireasby Federalflaws t,r;'
,WASTE MANIFEST
3. Generators Name and Malling Address1111
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4. s Generator's Phone( C Slate T s Id k ' �f
6. U EPA ID Num er °
5., Trans orter 1 Conn�pany Name ;
SAFEY KLEEN, v1 ��,, tau;
7. Transporter 2 Company Name 8. US EPA ID.Number D rr( irans "rter,sPhonb -.
E' ; StategT�rans ID r t t�
N �& 2�
0. 1p, US EPA ID Number
CO. 9. Designated Facility:Name and Site Address y rru * wt r r�
I bo F �TranspQrksPhone( & � ��� • � i
J F h a at d tPrx mra '`�
i v SAFETY—KLEEN .:CORD u a }
N L H actii sPlflone( � ) Y ,.r s $ y
960 Tt7RNPIKE�STREET ..
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o CANTON, MA. 0
� � _ �� i � .,. , .,. ;_ '� ' 12 Contalne[s��+ t• x Ei''.TOtal� �:`!r �Unit'�'f r ast+e O ' ,5 3Y�
I 11 US DOT Description( g Proper Shipping Name Hazard Class and/D Number)
tNol zr rs �,s l�f
a;R Hazardous Waste, Li ui'. - Tvpe Quantrt wt'No b'F
Q Liquid,, N.O.S. 9 i $
U NA3082 ,PGIII (DO11) (ERG #31) F` G AQ
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e r '; ;" 'ff KiFi9r4diing'Codes"for west '.Llsted v'.,,, 4 g
It` lons;for,Materla'!Listed Above i I de h slca/state and hazard Cod )
A diflonai Descr it ISCIO
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� ;t�.,�PENT"`tPHOTO SOLt?T'ION'��� � I t.I,:r ,•���.�.,��;, � �.',�,��� "'1,sT M>: 4� , �w� � ��
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17 THIS SHIPMENT :OFF WASTE IS4RES iRTCTED 1♦~ROM1LANt1 D7SPOSALr; S �tf ;e t, l 1P � ,f' �� �t,, 7
• f Rkr�pl �`•r, t�'j� YS �'f
ECAUgE' l Et CONCENTRA'CIO�V, b) !� T "VER;,I Sr«OVER''S?M(`t'P 1 'IL THE 4;b
15.Spoclal Handling Instructions and Additional information `
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SHIPPED TO SAFETY—KLEEN, CORP. ,'FOR RECYCLING & REFINING OF ,SILVER
EMERGENCY # (800)1229-3456 ER'60
a. by,,
O'I 16'.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this'oonsignmentare fully and accurately described above
?, proper shipping name and are classified,pecked,marked,and labeled,and are in all respects in proper condition for transport by highway p 'i�
U according to applicable international and national government regulations. ' ,
ticable :{
Q) If I am a large quantity generator,'I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically prac -rdg I
�' and that I have selected the practicetile metliodoftreatment,stbrage,or disposal currently available tome which minimizes the present and future threat to human health and theenvvon �3o t do ti
merit;OR,if I'am asmall queritity,generator,lhave made a good faith effort to minimize my waste generation and select the best waste management method that Is available to me f SHE
can afford. ` I t
9a t Date t.
p Printed?yped Name i atur Month `DeyYear,1
\
1 n
of mater
ials co, Receipt t
ant of
Acknowled em p . " ;
U a 7.Transporter ,1 9 � Month �Da �'�Ydar����±
�, A Printed/,Typed Name , azure
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— S67D
O 18r Transporter 2 Acknowledgement of Receipt of Materials, Month Da
E Pnnted/Typed Name Signature
z , rnt tla u
19.Discrepancy Indication space
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20.Facility Owner or Operator:Certification of,receipt of hazardous materials covered,by this manifest except as noted in Item 19.
SAFETY-KLEEN CORP. ri f Date ';
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T Pri ed/Type6d Name Signature Month. .Day W tw j
Form Approved OMB No.2050-0039.Expires'9/30192 vt Gt I
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EPA Form 8700-22'Rev.'9-88 Previous editions are obsolete'.