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0770 MAIN STREET (OST.) - Health (2)
770# MAIN STREET, OSTERVILLE A= 141 034 , ° J A .1 r' a f� 1 i Hazardous Materials Inventory Sheet Checklists F DPP TA Date I G 3 Physical Street Address-Check database to ensure it exists Working Phone Number Actual Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials) 114- Storage Information -location of storage, how long is storage for? �-`7—h-�—If none, note that. Disposal Information -where and who? If none, note that. Applicant Signature -understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -provide a vehicle washing policy and explain it- note that it was given Attach the Business Certificate with your sign off and comments **The inventory form should explain what the business consists of and the procedures' they are doing. Notes need to be left to explain what you discussed with them. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 for 4 years . A business certificate ONLY REGISTERS YOUR NAME in,town (which you must do by M.G.L.-it does not give you permission to operate.] Business Certificates are available at the Town Clerk's Office', 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: 1141 ZUf C) Fill please: APPLICANT'S YOUR NAME/S: PZAH .3 No TiT-�t�L {BUSINESS (y7(� YOUR HOME ADDR_ES�S:� b � .�l TC�/�l l p J;o�-�, �'. Z JG.b �. O J 1Z,./r( I �l V JC.v TELEPHONE # Home Telephone Number -7:7 - �- : 09 � 6, L• ,i4 '/ "e id Y! (•u}h•4:;;f�.1. l�v J'.`!'<_� .. NAME OF CORPORATION: NAME OF NEW BUSINESS 3,9L/ / T f�'f r�. �NW 7- TYPE OF BUSINESS C- W-LALL� t Av i C©tJS``4)_- ICv- 1 15 THIS A HOME OCCUPATION? YES NO-. ADDRESS OF BUSINESS 177DA f'lAiaJ 0 . MAP/PARCEL NUMBER � 1 ( vim (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations o.f the Town of Barnstable. This form is intended to assist you in obtaining the information.you may need. You MUST GO TO 200_Main St. - (corner.of Yarmouth Rd. & Main Street) to make sure you'have_the appropriate permits and licenses required toTega Brat our.-business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that.pertain to this type of business. Authorized Signature* COMMENTS: 03 2. BOARD OF HEALTH This individual has ben informed f pe it requi men . that pertain to this type of business. n a. u� I Authorized Signature** MUST COMPLY WITH ALL "AZ COMMENTS: ' 4R�=MATERIALS REGULATION G =rri c�S 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: Date: /CRUO TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: W9k_)fiaEjqe:Aj7 BUSINESS LOCATION: — �fL _ INVENTORY MAILINGADDRESS: �O 4 LAM-) STD �T�VI[1 � F�� TOTAL AMOUNT: TELEPHONE NUMBER: :SD -I ZS` 2848 CONTACT PERSON: 41Y' 44 J - EMERGENCY CONTACT TELEPHONE NUMBER: �'y�o '3098 MSDS ON SITE? TYPE OF BUSINESS: 0,Ox_)9_JZ-te! iotJ INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW --USED - Any other products with "poison" labels----- Paint & varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor& furniture strippers ther pro not listed which you feel Metal polishes b :�' O!r)thazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Commonwealth of Massachusetts , Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Governor Trudy Coxe Secretary.EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A RE �� '70 _ CERTIFICATION Property Address: 7ii0'.11 H ri t'-/ ST' G`,t t.:",fit c Address of Owner: F E B 2 8 199 5 Date of Inspection: Fes, Q jjkc% (If different) Name of Inspector:,C•,c, m. v j`-- HEALTH Dr: Company Name, Address and Telephone Number: 774VN OF BARNSTALIE Cice%V\(-t(r,-\t,^ink _ o21J W��i`����R(1J1 Hole�• 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 ofAhe 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 the Local Approving Authority _ Fails Date: �/�K ?91t�Inspector's Signature: ' � i �f The System Inspector shall submit a copy of this inspection report to the Approving Authority within 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)Iappropriate 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. 1 _ re INSPECTIONS SUMMARY: Check A, B, C, or D: Al SYSTEM PASSES: I I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) 9YSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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, cracked, structurally unsound, shows substantial infiltration or exhItration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a contorming septic tank as approved by the Board of Health. •` 1 .revised 51'_5/95; One Winter Street • Boston, Massachusetts 02108 • FAX(617) 556-1049 • Telephone(617)292-5500 `• Printed on Recvcied Pacer SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date •.i Inspection: BI SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken o. obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with �.pproval 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 systen-, will pass inspect lor;1f.(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMII�45 THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tribwaiy to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply wefl. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private v,ater supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the weii;i free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or leis than, 5 ppm. DI SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The oasis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded-or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. ,revised 8/15!551 2 t s 4 ; , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DI SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert dueto an overloaded,or,clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or:available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due-to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a.public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. irevised 8/15/951 3 L _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 1�u��eT1e2. Property Address: 7'70 7 A -� St• Us\.e `'c Owner: Date of Inspection: (--`� C1�� Check if the following have been done: I* Pumping information was requested of the owner, occupant, and 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 pan of this inspection. iy`a As built plans have been obtained and examined. Note if they are not available with N/A. Zhe facility or dwelling was inspected for signs of sewage back-up. JZThe system does not receive non-sanitary or industrial waste flow 4"The site was inspected for signs of breakout. All system components, exccludirtg the Soil Absorption System, have been located on the site. ,,, he 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. IL'T'he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. revised 8i15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: '770 Owner: �tvi`l z'[Ce t 1Ze:�`���r.,, Date of Inspection: `e- C��CIC�b FLOW CONDITIONS RESIDENTIAL: Design flow: eallons Number of bedrooms: Number of current residents:_ Garbage grinder (yes or no):_ Laundry connected to system (yes or no):_ Seasonal use (yes or no):_ Water meter readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL: _ Type of establishment: ��'•� "..-�r ►.'=,�,�-C Design flow: (0 allons/day Grease trap present: (yes or no)_eJ 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: C, OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: il/c;i c 141, System pumped as part of inspection: (yes or no)_.&/0 If yes, volume pumped: Qallons Reason for pumping: TYPE 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, ifany) Other (explain) •� /000 Cn S Stern ._1�J�ri�tl rD APPROXIMATE AGE of all components, date installed (if.known) and source of information: Sewage odors detected when arriving at the site: (yes or no)�(p revised 8/:5i55) 5 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �ieZ(e�.7C't�IT�Te..T Date of Inspection: 6 1 eb:CIS l�ci II SEPTIC TANK:_ c)j UU C C,r}I l U r�.s (locate on site plan) Depth below grade: Material of construction: zc'oncrete _metal _FRP _other(explain) Dimensions: 6 6 X Sludge depth: ,ti/oA/C Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: b/IC Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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.) A/ conl0o�r•�/i o 7f}rr r-oe GREASE TRAP:_ ljaOG'.S�/ (locate on site plan) i Depth below grade: / Material of construction: concrete _metal _FRP —other(explain) Dimensions: G X J Scum thickness: iVoN6 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:& 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.) o .revised 8/15/95) 6 _. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: '7?v� ►�►a�� Si. C�ie� \�c. Owner: �oSYcT�rr �C•� lT7 TRuT Date of Inspection: • ii= c ccb� )j1 cib TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _Concrete _metal _FRP _other(explain) Dimensions: Capacity: Qallons Design flow: Rallons/day Alarm level: Comments: (condition of inlet tee, condition,of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: f� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of b x, etc.) / Q _St— -o PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised B/.5/951 7 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 77G N"k 'S" Os rti•��� Owner: lAo�'wme" - —Cis„( Date of Inspection: �eb Il l cf SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: �{ _�' :5 i�/1 C leaching pits, number: — F'x� leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: _ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetal on,etc.) -�n `icY>n (i) �,/•�;-� i CESSPOOLS: _ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth 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) Dimensions: Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) $ revised 8i15i95) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 70 t-AAIA St• C �.e'..'�lc. Owner: lAo _QzftlTj Tee�T Date of Inspection: l—z�J.�f1�01q6 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ()00 %PEAS YRA -414 k o o 96 67 �--� Io5 DEPTH TO GROUNDWATER , Depth to groundwater: feet method of determination or approximation: r go j� O l p rn C � C.A 4. fl' a V: • izevised 8/15/95) 9 OF BAKNSTAB LOCATION 4W SEWAGE# VMLAGE Cj S`��/� �lLL @ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. rJ e J /VI C D m ISG'K-t S D/V SEPTIC TANK CAPACITY :aQ o Q LEACHING FACILITY: (type)/®-F46 W C11A A elf-f Fsize) / C s0©a NO. OF BEDROOMS BUILDER OR OWNER arc A1b 0,J,— Qng,.:./�- G PERMTTDATE: I = COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet, Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ell. .ere �•ni�� �� �� s '. s 1 i J �y TOWN OF BARNSTABLE LOCATION�;.// ,[1�/�l � SEWAGE# 'VILLAGE ���I2-�)l I1 F ASSESSOR'S MAP &LOT 0 3 7 pIidrr C�NAME&PHONE NO. SEPTIC TANK CAPACITY C7 11� n LEACHING FACILITY: (type) L5"AC- S (size) NO.OF BEDROOMS /� BUILDER OR OWNER 4S /� �)�A PERMITDATE: - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility / Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fff ility) Feet Furnished by o`L'9 ��6 j.+ -- �� 97 O S �- � �