HomeMy WebLinkAbout777B MAIN STREET (OST.) - Health 777 B Main Street, Osterville
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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: : e Lk"w — �13A 4 ptt dea 1i Mail To:
BUSINESS LOCATION: 727 Q* `Zlf, s Board of Health
Town of Barnstable
MAILING ADDRESS: /�Y �G e � h- P.O. Box 534
TELEPHONE NUMBER: Hyannis, MA 02601
CONTACT PERSON: dg�,J-e/ -g
EMERGENCY CONTACT TELEPHONE NUMBER: � J
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b 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 li uld vol me 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
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TOWN OF BARNSTABLE OMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body Shops s
O unsatisfactory- 4.Manufacturers
COMPANY A&&-E (see"Orders") 5.Retail Stores
_ 6.Fuel Suppliers
ADDRESS �077 a (;18SS: _ 7.Miscellaneous
QUANTITIES AND STORAGE (IN=indoors; OUT=outdoors)
MAJOR MATERIJkLS Case lots Drums Above Tanks Underground
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:
DISPOSAL/RE(;LAMATION REMARKS
:
1. Sanitary Sewage 2. Water Supply r �✓
O Town Sewer Public o
AlOn-site OPrivate
3. Indoor Floor Drains YES NO
O Holding tank:MDC
O Catch basin/Dry well
O On-site system =F t
4. Outdoor Surface drains:YES—ZNO O 7�P S:
O Holding tank: MDC
O Catch basin/Dry well
O On-site system
5.Waste Transporter
Name of Hauler Destination Waste Product
YES NO
1.
,2.
Per on (s) Interviewed Inspector Date