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1162 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00
Town of Barnstable
Board of Health
This is to Certify that WIANNO CLUB GOLF GROUNDS DEPT.
155 WEST STREET, OSTER VILLE, MA
Is Hereby Granted a License
FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS.
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This license is granted in conformity with the Statutes and ordinances relating there to,.and'
and expires 6/30/2015 unless sooner suspended or revoked.
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WAYNE MILLER,M.D.,CHAIRMAN
PAUL J.CANNIFF,D.M.D.
6/30/2014 JUNICHI SAWAYANAGI
THOMAS A.MCKEAN,R.S.,CHO
Director of Public Health
Town of Barnstable
Barnstable
�z Regulatory Services Department
cap'Public Health.Division
MAS& � 200 Main Street, Hyannis MA 02601 I
a
a 2007.
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 f ( �] , Thomas A.McKean,CHO
Application Fee: $100.00
ASSESSORS MAP AND PARCEL NO. I 1 S O a Q. DATE 5/q//V
APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE
MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS
FULL NAME OF APPLICANT , �0.�1 :aOViY1SO n
NAME OF ESTABLISHMENT W C`'-!62 c (-SOUVAr,
ADDRESS OF ESTABLISHMENT I S 5 W e-S Ct. 1) >Cf y l'l V
TELEPHONE NUMBER
SOLE OWNER: YES NO
IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL
PARTNERS:
IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO.
STATE OF INCORPORATION
FULL NAME AND HOME ADDRESS OF:
PRESIDENT
TREASURER
CLERK
SIGNATURE PPLICANT•
RESTRICTIONS: HOME ADDRESS
HOME TELEPHONE#
JAinspection handouts\Haz Mat Application2008.DOC
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MAIL-IN REQUESTS
Please mail the completed application form to the address below. Also include a copy of
your contingency plan (to handle hazardous waste spills; etc.) In addition,.please include
the required fee of$100. Make check payable to Town of Barnstable. Allow time for
in-house processing.. Our mailing address is:
Town of Barnstable
Public Health Division
200 Main Street
Hyannis,MA 02601
FOR FAXED REQUESTS
Our fax number is (508) 790-6304. Please fax a completed application form. Also,
please fax us a copy of your contingency'plan (to handle hazardous waste spills, etc.) In
addition, please mail the required fee of$100. Please make the check payable to: Town
of Barnstable. The check must be mailed to the address.listed above. Allow time for in-
house processing.
For further assistance on any item above,,call (508) 862-4644
Back to Main Public.Health Division Page
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JAinspection handoutsUIaz Mat Application2008000 ;
SPILL CONTINGENCY PLA-N
Emergency Coordinator, Name: �c�yi Jyl�nson �ro��'+[rrovY)JS Supf.
Address: . GI\)b 0 Stecv,ll 1�t14
Daytime Phone: 5og- gaga 4059 a
Evening Phone: ,5 g -3yy-Q a I
Fire Department: q//
Barnstable Public Health Division: 508-862-4644
DEP 24 Hour Spill Hot Line: 888-304-1133..
Waste Hauler: Name:
Phone: Boo-�y5- Bac�S
Building diagram indicating hazardous material/waste storage area, location
of absorbent scavenger materials, fire extinguishers, fire alarms (if present),
and evacuation route (if applicable).
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Actions to be taken to control a spill or release, and preventing it from
reaching a catch basin, sewer system or the ground.
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U51�5 0'10sorbAyiCs •.1c spill 1t,1 spec-, Ar
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a�ern'�toY► ri� �ql, v►w�`` �� dtree,�'� q�' ah sp►\�S
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1 L1 OF 89fiNS12,ABLF -� �J(wL)EF�BftUUND I U L—AND i:i+(:�� : (.r��.. fOr�r1U� Rf- -. t 1 Rr, i 1(_)N
/vo Vo LD A J •=0 S MAP NO. _�� S PORCEL NU. C �--�•�_ i A(f4�N(�.__T
ADDRESS OF TANK:_ /6'5" fit/��T 5���•� ���TV� VILLAGE:
humb�r Ytr�•t �'
..MAILING ADDRESS ( IF DIFFERENT FROM ABUV ; • tg0 ° �
OWNER NAME: l e�dd//i1iJ �U,C�' ? PNUNE: z �pf
)
INSTALLATION DATE: (�''' BY: I" "r't �r�'/1/►�G '�UR�S'�'uGi!)%1O
INSTALLER ADDRESS: 87 PU�/fd 5 ��" rT,t s f�a�� Il CERT ,iv0.
*TANK 'L' OCATION: ABOVE BELOW
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< D FQ I DC` TANK LOCATION WITH AQOmQCT TO mU I LD I ) by�fi
CAPACITY -?GU® oghYPE OF T ANK d� 6 'a,c:/� AGE YRS.—FT-OE•L/"CHEM•I-CAL-'I/n
5tG�t �,/Xsr/:'
TESTING CERTIFICATION [ ] PASS [ ]�'FA L :TEE
LEAK DETECTION [ ] CHECK IF N/A TYPE/,BRA^NU�'��� ' �P�®t ��s ,S�y ✓r✓/`��s1z`��/
ZONE OF CONTRIBUTION [ ] YES [X] NO DATE TO -'HE—PEMOVED
FIRE 'ADEPT. PERMIT ISSUED [� YES [ ] NO DATE
. CONSERVATION [ ] CHECK IF N/A DATEa
BOARD OF HEALTH TAG NO. [ � - ] DATE
' Y'3 6f l �s
i Nk PLEASEayPROVIDE ASKETC�HSHOyWINGTHE ;TANKLOC=ATIO,N�O"fVTHE6AC,K OFT:HISCARD ���.ti;,
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I%OWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION
ADDRESS: f i ..1 , f@ _. - MAP NO. I I . PARCEL NO.
OWNER NAME: 1 ?4 rl Alkm o C1 VILLAGE:
INSTALLATION DATE: � JBY:
ADDRESS:03 q �4f -) 4 ,. Q:C)- 1 CERT. NO.
ovo-ve TANK INFORMATION
i
LOCATION OF TANK: )t+ )7QMQ4AA t r'aa ..
CAPACIT461n TYPE AGE FUEL/CHEMICAL
TESTING CERTIFICATION C ] ,PASS C ] FAIL DATE
LEAK DETECTION Cv] CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION C ] YES V3 NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED C ] YES Cyi] NO DATE Ayto f"4smo
UUNSERVATION C V]�CHECK IF N/A DATE 1 tom.
BOARD OF HEALTH TAG NO. ]C ]C ]C ] DATE
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD.
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Departm(znt of Public Safety Division of Fire., Prevention k
1010 COMMONWEALTH AVE., BOSTON
REGISTRATION
tab e M Barns
..... 1 .
,, ..A . Ap ..T 1 80
...
I (City or Tow+) . .. .. IDatol.
This is to certify that... .................................Wi steno C1 ub ........ ........ .h
.► ..: . ..:.. ...... as, in accordance with the
provisions.of Chapter 148, Skt.ion 13,of the General LAws filed with me a certificate of registration set-
ting forth. that. .. . .. . .........................................................t ..........is the holder of the license granted `
... . .. .
................: ...........:. 11JU y...� .,.....:.........19...7. . for the lawful use of the buildinggs) or other structures)
situated or to .be situated at. .......... ,,,,,,Off West Bay Road,: Ostervi 11e, MA 02655. .. ...,. F
.. ..4scrKt and Numberi�� s
as related to the KEEPING,STORAGE,MANUFACTURE.OR SALE OFF FLA M ABLES.QR EX� O I
sVE
r ai i e w rk bwn of
(sien.turt.na oatciat Title),.. Bahnstable
IVotet A certificate of registration must be filed on or before April SOth of each resit.
(THIS REC.ISTRATION MUST BE CONSPICUOUSLY POSTED .ON THE PREMISES.),.
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TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRRATION
q.MAP NO. PARCEL NO. p
ADDRESS OF TANK: VILLAGE:
MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) : f
OWNER NAME: /14 / f..�t' I 1.,r �. PHONE:
INSTALLATION DATE: ✓ f BY:
INSTALLER ADDRESS: -CERT.140.
STANK LOCATION: "75 S> i Gs
(DamoR Z nG TANK LOQAT Z ON W Z TN munmaCT TO =u Z LLD Z NO)
CAPACITY TYPE OF TANK '°' AGE k oe� YRS. FUEL/CHEMICAL
TESTING CERTIFICATION [ ] PASS) C ] FAIL DATE
LEAK DETECTION [ ] CHECK IF N/A TYPE/BRAND.
``,, lqqc��
ZONE OF CONTRIBUTION [ ,] YES COX] NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED [ ] YES C ] NO DATE
CONSERVATION [ ] CHECK IF N/A DATE
BOARD OF HEALTH TAG NO. C ] DATE �C) �
?k PLEASE !PROVIDE A SKETCH SHOWING . THE -TANK LOCATION .ON THE BACK OF THIS CARD
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