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Home My WebLink About0016 WEST BAY ROAD - Health 16 WEST BAY ROAD OSTERVILLE A= 117 -095 -y _ . I Commonwealth of Massachusetts Title 5 Official Inspection Form U"I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 16 West Bay Rd Property Address t'? Cumberland Farms, ` Owner Owner's Name �+ information is required for every Osterville ✓_ MA 02655 8/162018 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brian A Travis use the return key. Name of Inspector Howland Disposal Service rab Company Name 20 Roberts Rd ILA Company Address Plymouth MA 02360 City/Town State Zip Code 508-746-9600 �� y SI 13733 Telephone Number License Number B. Certification 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 of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/16/2018 Inspector's Signature - Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i I Commonwealth of Massachusetts w W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 16 West Bay Rd Property Address , Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 page. City/Town State Zip Code Date of Inspection B. Certification (cant.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are. indicated below. Comments: t f B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement orrrepair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is,structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally'sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): 4 ° t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken.or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ON ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below): ❑, distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ON ❑. ND (Explain below): ❑ obstruction is'removed ❑Y ON ❑ ND (Explain below): C) 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 public health, safety or the environment. 1. System'Will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a'manner which will protect public health, 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts v Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 West Bay Rd i Property Address Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. []The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. [—]The system has a septic tank and SAS and the SAS is within 60 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than'100 feet but 50 feet or more from a private water'supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to 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 ❑ ® Static liquid level in.the distribution box above outlet invert due to an overloaded I or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 page. Cityfrown State Zip Code Date of Inspection B. Certification (cost.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ z Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of 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 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached,to this form.] El ® The system is a cesspool serving a facility with a design flow of 2000gpd= 10,000gpd. ® 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large.systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ 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 If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large. system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °w 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is Osterville MA 02655 8/162018 required for every page. City/Towmr State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? t ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpdx#of bedrooms): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Convienence store Design flow(based on 310 CMR 15.203): 440 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 2,700 sq/ft Grease trap present? ❑ Yes ® No Industrial waste holding tank present? E Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No. Water meter readings, if available: town file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) °Last date of occupancy/use: occupied Other(describe below): General Information Pumping Records: Source of information: Semi Annual - Howland Disposal Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: i gallons l How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract EJ Tight tank: Attach a copy of the DEP approval. Other(describe): 1,000 gallon grease tank converted to septic tank t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ° 16 West Bay Rd M Property Address Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: . 49 years old. Building construction 1969 Were sewage odors detected when arriving at the site? ❑ 'Yes ❑ No Building Sewer(locate on site plan): 34" Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): > 100' Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): All joints and components are intact and are fully functional. Septic Tank (locate on site plan): 3' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2,000 gallons 1„ Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle T, Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Field measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is structurally sound. No tee present on inlet pipe. Liquid level below inlet invert. Outlet lid is under pavement Grease Trap (locate on site plan): 1,3„ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 1,000 gallons 1„1 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 2'6" 2018 Date of last pumping: Date Date l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 aN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No tee on inlet pipe. Tank was converted to a septic tank. Liquid level above inlet tee. r Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: i Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): s. ' *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments. M 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): .Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Could not inspect D box, located under pavement. I Pump Chamber(locate on site plan): - Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): M * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments W GSM sa'' 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 page. City/Town State Zip Code Date of Inspection D. System Information.(cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system, Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of failure Cesspools (cesspool must be pumped as part of inspection) (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 ❑ Yes ❑ No l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is required for every Clsterville MA 02655 8/162018 page. Cityrrown State Zip Code Date of Inspection, D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): - r E ,t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) IM ^�c� C DATA \ ' . �»\ At . ] »�p Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is required for every Osterville MA 02655 8/162018 page.- City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water 1 ® Check cellar ® Shallow wells Estimated depth to high ground water: N/Afeet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: ` Could not establish groundwater elevation, no records on file with BOH. No area at location to dig a test hole. y Before filing this•Inspection Report, please see Report Completeness Checklist on next page.. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 P Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 16 West Bay Rd Property Address Cumberland Farms Owner Owner's Name information is required for every Cisterville MA 02655 8/162018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file f y t5ins.doc•rev.6l16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. � I Fee C/V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -;;TOWN OF BARNSTABLE, MASSACHUSETTS 2ppliCatlon for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair,(--Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /6 ullv 6 wY Owner's Name,Address,and Tel.No. 0S)--eA-Vi4-t+C4=— CC/OfgeAe_Lfjb Assessor's Map/Parcel S R12_Z „J 1,A.), d 5 D$--'2,-7 v ( 2_ Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Buflding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) AelL_ G ,Z,,�/S�C770eJ TG°iS 9'7oZ0�� #2,0 7D Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ��' ' Date Issued LIP,/ 117 " No. ( Fee D"" ?"I, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVIS ,OWN OF BARNSTABLE, MASSACHUSETTS Yes IQN, , 2ppliLatlo,n for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair.(k,..,Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ��6v137— 4r Owner's Name,Address,and Tel.No. N�4iuc�t d sT�►.h V)L_ cv�is�.c_(s�r d �.c•Z.y s �� r Assessor's Map/Parcel R-IZZEEA/G,v. /,3p,V19AJ_ 5'08--2-7 O / Z_ Installer's Name,Address,and Tel.No`. Designer's Name,Address,and Tel.No. Type of Buildirigc -7g<c/,aZ - Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date r ` Title Size of Septic Tank ' Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /5.0 2 j4o %1 6 G770.J �/�j�/� 9-7_1 0 Za IC&i eS 0/0 �a��D.��.��`S , S end ��/�.� ' / o .1 i%v ' 7- r ,%� 41 /� Lc s- 2 _�S o .+c S a 76/ j Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental.Code and not to place the system in operation until a Certificate of Compliance has beei]'issued'bythisoard Me* - Signed Date L L O Application Approved by :Date /I Application Disapproved by Date for the following reasons Permit No. �� J�\ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance.,~ THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Re aire� Upgraded( . ) Abandoned( ).by IcO g LzT at S y has been constructed in accorr ce_�' with the provisions of Title 5 and the for Disposal System Construction Permit No_DC/�s-Z ) dated lc .�,. Installer 20(3e_nt-T` Oulir Co 5,,..C.,_- Designer r #bedrooms Approved design flow _ and The issuance of this permit shall not be construed as a guarantee that the system wil'1'f motion as desi ned. Date - f I / Inspector � �. ---------------------------------------- No. C7"f I Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS -Misposal *pstem Construction.3permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at (� Lk-) c- ST t - i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date ox Approved bye wBa y Rd Osterville MA 9/10/2018 Accu sepcheck nal pass. 1. Septic tank 1 and II tops are 5 thick and are pre existing, have no apparent cracks. 2. Septic tank I(GT) requires and inlet tee and H-20 covers. 3. Septic tank II requires inlet tees and H-20 covers. 4. Septic tank II requires new outlet tee and a riser with and H-20 cover to grade. 5. Requires a sched 40 PVC pipe from septic tank II to dbox to replace Cl pipe 6. Dbox requires a riser and H-20 cover to grade. Dbox requires speed levelers to equalize flow. 7. Leach pits need to have H-20 covers especially#5 on sketch which requires a new riser too. V '710 r _ //- - - 0 9 C� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V _0 16 West Bay Road, Osterville, MA F, Property Address p.m1 t� Cumberland Farms, Inc. 5 Mizzen Lane ti Owner Owner's Name information is Bourne MA 02532 8/22/2018, 9/7/2018,' required for every page. Cityrrown State Zip Code Date of Inspection tom: Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 5�/� on the computer, 133 use only the tab Joseph M Martins key to move your Name of Inspector cursor-do not Accu Specheck use the return Company Name key. 17 Northside Drive of-16 Company Address South Dennis MA 02660 Cityrrown State Zip Code few 508-385-5891 SI 147 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true;accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9/10/2018 nsp tor's Signature f Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority., Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 8/22/2018, 9/7/2018 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the ure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failur Iteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): SEE ATTACHED NOTES PG 2A t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 16 w Bay Rd Osterville MA 9/10/2018 Accu sepcheck Condtional pass. 1. Septic tank I and II tops are 5"thick and are pre existing, have no apparent cracks. 2. Septic tank I(GT) requires and inlet tee and 1-1120 covers. 3. Septic tank II requires inlet tees and H-20 covers. 4. Septic tank II requires new outlet tee and a riser with and H-20 cover to grade. 5. Requires a sched 40 PVC pipe from septic tank II to dbox to replace Cl pipe 6. Dbox requires a riser and H-20 cover to grade. Dbox requires speed levelers to equalize flow. 7. Leach pits need to have H-20 covers especially#5 on sketch which requires a new riser too. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 P Y ry u 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 8/22/2018, 9/7/2018 page. CityrFown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water vel in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or even distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or re ace ❑ Y ❑ N ❑ ND (Explain below): ❑ The system re/inspe g more than 4 times a year due to bra "n or obstructed pipe(s). The system will paf(with approval of the Board of Healt❑ brokeneplaced ❑ Y ❑ ❑ ND (Explain below): ❑ obstrued ❑ Y N ❑ ND(Explain below): 3) Further Evalua/ee quired by th oard of Health: ❑ Conditions require f er evaluation by the Board of Health in order to determine if the system protect ublic health, safety or the environment. a. System unle Board of Health determines in accordance with 310 CMR 15.303(1)(b sy em is not functioning in a manner which will protect public health, safety and o ent:t5insp.doc•rev.7/26/2018Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 8/22/2018, 9/7/2018 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated etland or a salt marsh b. System will fail unless the Board of Health (and Public ater Supplier, if any) determines that the system is functioning in a manner t t protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption s tem (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a su ace water supply. ❑ The system has a septic tank and SAS and th AS is within a Zone 1 of a public water supply. ❑ The system has,a septic tank and SAS an he SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS nd the SAS is less than 100 feet but 50 feet or more from a private water supply well".. Method used to determine distance: **This system passes if/absent lysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicatpresence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, per failure criteria are triggered. A copy of the analysis must be attached to this form c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 8/22/2018, 9/7/2018 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 SAS, cesspool or privy is below high ground water elevation. El ® Any portion of 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 1 of a public water supply 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a f cility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the wing, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 fee surface drinking water supply ❑ ❑ the system is withi 0 feet of a tributary to a surface drinking water supply ❑ ❑ the system is Gated in a nitrogen sensitive area(Interim Wellhead Protection Area—IW )or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane - Owner Owner's Name information required or every i Bourne MA 02532 8/22/2018, 9/7/2018 f e page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface'sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 2/2018, 9/7/2018 page. Citylrown State Zip Code Aate of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): /10gpdx#of oms(actual): DESIGN flow based on 310 CMR 15.203 (for exam bedrooms): Description: Number of current reside/edetr? Does residence have a g ❑ Yes ❑ No Does residence have a w ? ❑ Yes ❑ No If yes, dischaIs laundry on a separatenclude laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 141 9 ( Y 9 (gP ))� Detail: 2016: 54,000 G 2017: 49,000 G Sump pump? ❑ Yes ® No PRESENT Last date of occupancy: Date l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 West Bay Road, Osterville, MA Property Address h Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 8/22/2018, 9/7/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: mini market Design flow(based on 310 CMR 15.203): 200-270Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 2700 FT2 Grease trap present? ® Yes ❑ No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: 141 GPD Last date of occupancy/use: 9/7/2018 Date Other(describe below): 3. Pumping Records: Source of information: PUMPED IN 2007 PER WWTP Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1200 gallons How was quantity pumped determined? ESTIMATE Reason for pumping: PUMPED FULL LEACH PIT TO SEE PIPE t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 I I c Commonwealth of Massachusetts Title 5 Official Inspection Form ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 16 West Bay Road, Osterville, MA . Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owners Name information is required for every Bourne MA - 02532 8/22/2018, 9/7/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): WITH GREASE TRAP OR FIRST SEPTIC TANK FOR NON BATHROOM INPUT Approximate age of all components, date installed (if known)and source of information: 49 YEARS. PER PLAN DATED 1969 FROM OWNER Were sewage odors detected when arriving at the site? ❑ Yes ® No 5., Building Sewer(locate on site plan): Depth below grade: IN FLOOR BUILDING IS ON SLAB feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: EXACT LOCATION UNKNOWN feet Comments (on condition of joints, venting, evidence of leakage, etc.): FLUSH TESTED BATHROOM-GOING INTO SEPTIC TANK H. t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 8/22/2018, 9/7/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ' ® concrete ❑ metal ❑fiberglass ❑ polyethylene ® other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: APP 12X6X5 2000 G Sludge depth: 10 INCHES Distance from top of sludge to bottom of outlet tee or baffle NO OUTLET TEE Scum thickness 0" Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee,or baffle N/A How were dimensions determined? CORETAKER Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,.etc.): HAS INLET PIPE COMING INTO TANK PARTIALLY SUBMERGED. FOR BATHROOM ONLY INLET COVER TO TANK IS EXPOSED. OBSERVED NO OUTLET TEE AT END OF TANK W MIRROR. NEEDS OUTLET TEE AND H-20 STEEL COVER TO GRADE. THIS TANK RECEIVES FLOW FROM THE GREASE TRAP. THERE IS NO TEE COMING FROM THE GREASE TRAP. t5insp.doc•rev.7/6=18 TiBe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 8/22/2018, 9/7/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: APP 8.5X6X5 1000 G ON PLAN Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 36" Date of last pumping: UNKNOWNDate Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): THIS IS TANK IN A PARKING LOT.THIS IS LISTED AS GREASE TRAP ON ORIGINAL PLAN AND APPEARS TO BE CONNECTED TO THE BIG KITCHEN SINK. THE CAST IRON INLET PIPE IS PARTIALLY SUBMERGED. THIS TANK CONNECTS TO THE 2000 GALLON SEPTIC TANK 8. Tight or Holding Tank(tank must be pumpe/sEl e on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ ene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 8/22/2018, 9/7/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) ' 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping; Date Comments (condition of alarm an f a itch etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if;present must be opened) (locate on site plan): Depth of liquid level above outlet invert AT ONE INVERT ONLY Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DBOX WAS EXPOSED AND CAST IRON TEE INTO DBOX WAS BLOCKED AND WAS CLEARED. DBOX IS H-20 AND IN GOOD CONDITION. NEEDS SPEED LEVELLERS AND RISERS AND H-20 COVER TO GRADE. t5insp.doc•rev.7/262018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. . 5 Mizzen Lane Owner Owner's Name information is Bourne MA 02532 8/22/2018, 9/7/2018 required for every page. Citylrown State Zip Code D to of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: E l Yes ❑ No" Alarms in working order: El ❑ No" Comments (note condition of pump chamber, cpurtenances, etc.): * If pumps or alarm/ainwhy: rking order,-system is a conditional pass. 11. Soil Absorption Socate on site plan, excavation not required): If SAS not located, Type: ® leaching pits number: 2 6'X6'W STONE H-20 ❑ leaching chambers number: , ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 coy Commonwealth of Massachusetts Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 8/22/2018, 9/7/2018 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): LEACHING PIT CLOSEST TO TANKS IS FILLED OVER PIPES LIQUID LEVEL IS 70". IT WAS PUMPED BY RBO TO CHECK PIPE. THIS LEACH PIT COVER IS SUNKEN AND UNSAFE AND NEEDS TO BE SECURED OR REPLACED. 2"D PIT IS DRY WITH LITTLE NO STAINING. STONE IS CLEAN. SOME EFFLUENT DRIBBLING INTO THIS PIT. THERE IS UNEVEN FLOW ALLOCATION FROM THE DISTRIBUTION BOX. GRADE TO SAS BOTTOM IS <11'. 12. Cesspools (cesspool must be pumped as part of inspection) (locate 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 ❑ Yes ❑ No Comments(note condition of soi signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 8/22/2018, 9/7/2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, sign f Vhydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 812212018, 9/7/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below 0 drawing attached cenarately_ — - For% - Al r 3 `f O /fit-ZZ' IN =37' - A S Z�' , -= 23r R3/F_ 36 B3A NTS ffinsQ doe•Ien 7f t8 Tme s 0WOM Bye am Fomr Susie Pase'6 at's I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� 16 West Bay Road, Osterville, MA Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is required for every Bourne MA 02532 8/22/2018 9/7/2018 page. Cityrrown State zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >17 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: , ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: GOOGLE MAPS, CAPE COD COMMISSION, FRIMPTER You must describe how you established the high ground water elevation: SITE IS 37'ASL. CCC GROUNDWATER CONTOUR IS 16'ASL W A MAX RISE OF 4'. GRADE TO SAS BOTTOM IS <=11'. SEPARATION MATH: 37-(16+4+11)=6 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts IvyTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 West Bay Road, Osterville, MA I Property Address Cumberland Farms, Inc. 5 Mizzen Lane Owner Owner's Name information is Bourne MA 02532 8/22/2018, 9/7/2018 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A Inspector information:Complete all fields in this section. ® B.Certification: Signed&Dated and 1, 2,3, or 4 checked ® C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included TOP OF FOUNDATION TOP OF GRADE=0 --�gAffig=usted _= t ASH7:!JCH AmtofStone= undwater=Ob Sroundwatm= Mnsp.doc•rev.MAM18 rites orrecm aeon Fam:&Mwrfaoe sewage Dqxnw systwn•Page to of le TKME Town of Barnstable Barnstable ' °"' Regulatory Services Department RNSM �`��" 039 ,� Public Health Division m Mare 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4990 6654 September 7, 2018 CUMBERLAND FARMS, INC 5 MIZZEN LANE BOURNE, MA 02532 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 16 West Bay Road, Osterville,MA was inspected on 08/16/2018 by Brian A. Davis, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15,00) due to the following: • Backup of sewage into the building due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE B. RD OF HEALTH c ean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\l6 West Bay Road Osterville.doc I - �TFtE Tp� Town of Barnstable • snjuvsrnsLe, Regulatory Services Department ArfD MA'S a Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR-15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. 0-11ackup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE-0) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER ❑ ' Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc I ��e�.�eef+11 e�.....�,�.z�_.,,.�_xnrn:.�xx:da^�^ _e�...: .;,�-=•-.:_,. ,...._..:,,�.:...._.,.. ...:��r..v-v:.,.., ,,.. ..a�w,"',aameat�s•.rm'wt+.y .a.,.:u,.�..o.- .a'�.crin �"�'ar _ ._�..v�;_ �.�,..a„e:.:....,�,...�.vM,m w,u�.u�w,.� I MASS. * Town of Barnstable � MASS. i639. 10 Argo" Inspectional Services Public Health Division Thomas McKean, Director r 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 v February 20, 2020 Harry Patel' Express Food Mart 16 West Bay Road Osterville, MA. 02655 17coptk Mr. Patel, Thank you to for your cooperation letting us perform a required hazardous materials yearly inspection. This letter contains information from that visit that will help you to become compliant with the Town of Barnstable Ordinance: Chapter 108 Hazardous Materials Enclosed are copies of Chapter 108: Hazardous Material Ordinance and a copy of labeling requirements for all waste products in your shop. I have also enclosed a spill plan/contingency plan thatis required. Please note the problems identified at your place of business during the hazardous materials inspection and the corresponding recommendations listed below: PROBLEM: • Material Safety Data Sheets not available during visit. ORDER: • Massachusetts General Law-Right to Know Law states that " MSDS's should be filed in an organized manner at a central location in the workplace so that the employer can easily provide an MSDS if an employee requests one " • Town of Barnstable Ordinance Chapter 108: Hazardous Material section 108-4 (B) Inventory and registration states that the "material safety data sheets shall be made available upon request of the Health Department. PROBLEM: 0 Fire Extinguishers are not recharged to current date and are not readily assessable. Q ORDER: • Please have all extinguishes re-charged, assessable, and clearly marked with placard. PROBLEM: • Business license issued from the clerk's office not visible ORDER: . • Please post current business license PROBLEM: • Spill/Contingency Plan must be posted. ORDER: • Make and post plan,guideline enclosed to make it easier for you PROBLEM: • Spill kit and absorbent pads, speedy dry not readily available ORDER: • Make spill kit and supplies readily available and out in the open PROBLEM: • You do not have a current Hazardous License issued from the Town of Barnstable Health department. ORDER: • Please bring the enclosed license to the Board of Health to obtain a current license Again thank you for your continued cooperation and I will be back on March 19th,2020 between 9 AM and 230PM for a final inspection report. I realize that the quantity fluctuates during the year and the total may seem high in February, but this quantity reflects the yearly average. If you have a difference of opinion, please feel free to contact me directly. If you have any questions about the problems, the recommendations, or you need further information, guidance, or assistance,please do not hesitate to contact me directly. Respectfully, chester.johnson@town.barnstable.ma.us 508-862-4645 C. Gus Johnson Hazardous Material Specialist `oFIKE roly� Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 • snRMABLE.9` 200 Main Street• Hyannis, MA 02601 �p�EO MA�p`0 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: 9reM Aofl- Date: Location/Mailing Address: Contact Name/Phone: ( 14 [7 Inventory Total Amount: �� MSDS: u 1 License#: _ Tier II : 5 Labeling: PIA Spill Plan: Oil/WaterSeparator: /Vtq Floor Drains: —O Emergency Numbers: V Storage Areas/Tanks: 1 Emergency/Containment Equipm t: 5Po f i j c Waste Generator ID: Waste Product: Date&Amount of Last Shipment/Frequency- Licensed Waste Hauler&Destination: UM nd Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers ydraulic fluid (including brake fluid) V Windshield wash otor oils iscellaneous Corrosives ' t fuel, aviation gas � sspool cleaners Miesel fuel, kerosene, #2 heating oil �?isinfectants iscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages ✓ Pesticides: Caulk/Grout insecticides, herbicides, rodenticides ------ Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible &varnish removers, deglossers Leather dyes o/ Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFO RMATION/RECOMMENDATIONS: r Pl Inspector: Facility Representative: WHITE COPY- HEALTH DEPARTMENT/CANARY COPY- BUSINESS `°pTMETOh� Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-7s0-6304 C9B"" SS.MA 200 Main Street• Hyannis, MA 02601 039.a,. TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT rF0 MP'� Business Name: 5 Date: Location/Mailing Address:. CLS il-r� Ic- Contact Name/Phone: ' e (s 5-a.s— �9 6-- Inventory Total Amount: MSDS: License#: Tier II : Labeling: Spill Plan: Oil/WaterSeparator: Floor Drains: Emergency Numbers: Storage Areas/Tanks: Emergency/Containment Equipment: Waste Generator ID: Waste Product: Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield wash Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECOMMENDATIONS: Cam Inspector: , Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS J, S -' °r:IKE►oq Town of Barnstable Office:508-862-4644 Public Health Division Fax:508a90-6304 BARNST 200 Main Street• Hyannis, MA 02601 039. MA+ TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: .s ry).7„•.1-* - Date:, Location/Mailing Address:{_I t„r to/ .'► Y' a, Its' a 0LT "I ! 1; r Contact Name/Phone: T V( A eQfr° F kQ L1-e) y d)I +� Inventory Total Amount:% MSDS: License#: Tier II : Labeling: Spill Plan: Oil/WaterSeparator: Floor Drains: Emergency Numbers: Storage Areas/Tanks: Emergency/Containment Equipment: Waste Generator ID: Waste Product: Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111,-Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze ,. �-` Dry leaning fluids Automatic transmission fluid "" �,Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield.wash Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners, Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout , insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and-polishes . Wood preservatives(creosote) Asphalt&roofi'ng tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes -.. Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes AOther chlorinated hydrocarbonsr Laundry soil.&stain removers (including carbon tetrachloride) (including bleach) 'Any other products with "poison-labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS:. ORDERS: INFORMATION/RECOMMENDATIONS: s Inspector: 4 Facility Representative: WHITE COPY- HEALTH DEPARTMENT/CANARY COPY- BUSINESS ., . `°FAME rop Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 9 BARN R.S. � 200 Main Street• Hyannis, MA 02601 �p 63q.ewe lEO MAC TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: WMS)Vl C-- Date: QC/0/0 Ia+� Location/Mailing Address: 6 w B — Contact Name/Phone: b Inventory Total Amoun MSDS: _ License#: 6 Tier II : Labeling: tA09 Spill Plan: Oil/WaterSeparator: Floor Drains: Emergency Numbers: Storage Areas/Tanks: Emergency/Containment Equipment: Waste Generator ID: Waste Product: Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: !� LIST OF TOXIC AND HAZARDOUS MATERIALS , NOTE: Under the provisions of Ch. 111, Section 31, of the General ws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield wash Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECOMMENDATIONS: S ` `e Inspector: Facility Representative: u WHITE COPY- HEALTH DEPARTMENT/CANARY COPY-BUSINESS Number Fee . 1350 THE COMMONWEALTH OF MASSACHUSETTS ' $50.00 Town of Barnstable Board of Health This is to Certify that Express Mart ................................................................................................................................. 16 West Bay Road, Osterville, MA ................................................................................................................................. ---------------------7------------------ Is Hereby Granted a License For: Storing or Handling 26 - 110 gallons of Hazardous Materials. .................................................................................................................................................................... Restrictions: ................................................................................................................ ...................................................... This license is granted in'conformity with the Statutes and ordinances relating there to, and expires 06/30/2021 unless sooner suspended or revoked. - --------------------------------------- JOHN NORMAN DONALD A.GUADAGNOLI,M.D. 07/01/2020 PAUL J.CANNIFF,D.M.D. THOMAS A.MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable Inspectional Services BARNSTABLE Public Health Division sm«e�E�639M120-14 9}NNhS 48tE ' � p 1fi39-2014 1�&UW9rABM * Thomas McKean, Director 139. 200 Main Street,Hyannis,MA 02601 . Office: 508-862-4644 Fax: 508-790-6304 ') Ml APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE an HAZARDOUS MATERIALS ' IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st—JUNE 30th). APPLICATION FEES d Gr l CATEGORY 1 PERMIT 26- 110 Gallons: $ 50.00 __ t�=_,. CATE(3OatY 2..PERMIT .H I -499_.Gallons: _ $125.00 El CATEGORY 3 PERMIT 500 or more Gallons: "$150.00 s *A late charge of$10 00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? ✓YES_NO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO. 4.- FULL NAME OF APPLICANT: 'V4--A-s CSh 5. NAME OF ESTABLISHMENT:,w�z z-f fj�;,S V-A CA-T A- 6. ADDRESS OF ESTABLISHMENT: 1 C� "C�IR A O S-�e.y y I k 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: 8. 'TELEPHONE NUMBER OF ESTABLISHMENT: i ?"-02\Z 1--o 2�g 9. EMAIL ADDRESS: C14yGh 2 !G,hof) (0 m 10. SOLEOWNER: YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: Vt1'Ccs�) CORPORATION NAME G's A G S Co-v?. PRESIDENT pCAy0�, TREASURER CLERK �SGTY-\ 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: • SIGNATURE OF APPLICANT DATE SIGN 920�0 Q:\Application Forms\Haz Mat Appli Draft Jan2019.docx r Number Fee 1350 THE COMMONWEALTH OF MASSACHUSETTS $50.00 Town Hof Barnstable Board of Health This is to Certify that Express Mart 16 West Bay Road, Osterville, MA .---------------•-----------------•------------...-•-•--.........---------•--......---......----........---..............--......--••--------.----.....------......------ Is Hereby Granted a License For: Storing or Handling 26.- 110 gallons of Hazardous Materials. ...................................................---------------------------- .... Restrictions: This license is granted in conformity with the Statutes and ordinances relating there to, and expires 06/30/2020 unless sooner suspended or revoked. ---------------------------------------- JOHN NORMAN DONALD A.GUADAGNOLI,M.D. 02/28/2020 PAUL J.CANNIFF,D.M.D. THOMAS A.MCKEAN,R.S.,CHO Director of Public Health �P Ind L4cprC;, .T� Town of Barnstable mot . Inspectional Services BASTABLE Public Health Division fiR,T°R S M:.15 M�iPS:"' N l5 J i.nv Y S PhiM5T4fi.c T j - o � 1.F?9-201i i�l BAM MASS. * Thomas McKean, Director Ar1 O3 9. ta`0 200 Main Street, Hyannis,MA.02601 Office: 508-862-4644 Fax: 508-790-6304' ' APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE.GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS' GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS DULY I st—JUNE 30th). APPLICATION FEES_ CATEGORY 1 PERMIT 26— 110 Gallons:° $`50.00 CATEGORY 2 PERMIT 111 -499 Gallons: $125.00 CATEGORY 3 PERMIT 500 or more Gallons: $150.00 0 . *A late charge of$10.00'will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. �f J 2. IS THIS A PERMIT RENEWALS YES /I NO. IF YES,.SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONINGBUILDING APPROVAL FOR HAZARDOUS MATERIALS'STORAGE/USE OF • GREATER THAN HOUSEHOLD QUANTITIES(25 GALLONS)? YES NO.- 4. FULL NAME OF APPLICANT:. N GY'1 side 5. NAME OF ESTABLISHMENT: "Ex}-6es-S N G-r l O S 6. ADDRESS OF ESTABLISHMENT: \i J SC';- BA C'1 S Y y (11 e N I- c32G s5 7. MAILING ADDRESS (IF DIFFERENTYROM ABOVE: 8. TELEPHONE NUMBER OF,ESTABLISHMENT: o Z� _ 6 3 88 9. EMAIL ADDRESS: �n GTS►-\S 12.Q"A Ghbo . o 10. SOLEOWNER: .✓•YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: C��tS1c�d11 P , CORPORATION NAME ~3 -4S� r`� g.SS PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: - TELEPHONE#: COMPANY ADDRESS EMAIL: r *SIGNATURE OF APPLICANT A DATE - - a 0 a a Q:\Application Forms\Haz Mat App Revised 09-10-18.docx Number Fee 1230 THE COMMONWEALTH OF MASSACHUSETTS $so.00 Town of Barnstable Board of Health This is to Certify that Cumberland Farms Store #2269 16 West Bay Road, Osterville, MA Is Hereby Granted a License For: Storing or Handling 26 - 110 gallons of Hazardous Materials. ---------------- ------------------------------------ ------------------------------------------------------------------ -------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2019 unless sooner suspended or revoked.. l ---------------------------------------- PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2018 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health TfownYOf B . risable f egulator , Services , .: Richard V Scali, Director IME ' 'Public Health Division 8 BARNSTABLE, • Th m omas 1VIcKean, Director` y ;; ass. 200 il'Ia n Street, HS aunts,MA 02601 ; M.; Office: 508-862-4644; . Fax:,5%790 6304 APPLICATIONF'OR PERMIT°TO STORE AND%OR UTILIZE HAZARDOUS.MATERIALS` ' ' IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER'108, HAZARDOUS,MATERIALS,ALI.BUSINESSES THAT HANDLE OR STORE`HAZARDOUS. MATERIALS GREATER THAN HOUSEHOLD QUANTITIES A.RE REQUIRED TO OBTAIN AN' ANNUAL PERMIT(RUNS'kJULY I st.,DUNE 30tfi). :APPLICATION FEES CATEGORY tPERMIT 26Y—:110 Gallons: $ 56.00 CATEGORY 2PERMIT 111 =499'Galh)fi : $12:5100 CATEGORY.3'PERMIT 500brr more Gallons: " $150:00 *.A late chats of$'A.00:will be assessed.if payrriet t is riot received byJuly lst. , I. ASSESSOR'S MAP AND PARCEL NO., x.. ,, . IS THIS A'PERMIT RENEWAL? ,.,2 YES NO. IF YES,'j SKIP QUESTION 3. 1 FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL'FOR HAZARDOUS MATERIALS STORAGVUSE-OF • GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)?. YES NO. 4. FULL NAME OF APPLICANT: 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENTS 16 53"62 t/ , . r'c�"l,/'t �llo / q -7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE:/ JC 8. TELEPHONE NUMBER OF ESTABLISHMENT: .gF7.-9.23Z 9. EMAIL ADDRESS: .Z.Si0.4 Vacc. &eewo ",6jj��ems: 60ss 10. SOLEOWNER:, t/YES_NO IF.`NO, NAME OF PARTNER: 11. FULL NAME;HOME ADDRESS,AND TELEPHONE#OF: CORPORATIO_ N NAME PRESIDENT TREASURER CLERK _. 12. IF PREPARED BY OUTSIDE PARTY NAME: r. TELEPHONE COMPANY ADDRESS 3 EMAIL: . SIGNATURE OF APPLICA C:\Users\Deco(lik\AppData\Local\Microsoft\Windows\ empor met ontent Outlook\BMQD49H2\HQZMAT APP 2017 REVISED.docx Richard Fournier `. b "Tax Manager Number Fee 1230 - THE COMMONWEALTH OF MASSACHUSETTS $so.00 Town of Barnstable Board of Health This is to Certify that Cumberland Farms Store #2269 16 West Bay Road, Osterville, MA Is Hereby Granted a License For: Storing or Handling 26 - 110 gallons of Hazardous Materials. -------------------------------- ------------ ------------- --------------_---------------- =----------------------------------------------------------y-------- �O ----------------------------------------------------------------------------------------------------------=-------------------------=--------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2018 unless sooner suspended or revoked. ---------------------------------------- PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2017 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health Cr T, { TRow of Brnstable egn atory Services a �� Richard V. Scah, Director � r Public Health Division BARNSTABLE { BPR45fAUtE•iEx1ERVll1•COTUII•HYAi:F'IS ` WA U!5Mt -MI:RVILLk•1'fcSTWN5fA0'.F ��•� - Thomas McKean, Director 1639-2014 1639. �s``MASS. � 200 Main Street, Hyannis, MA 02601 h / A Office: 508-862-4644 6 Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st—JUNE 3Oth). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: .$ 50.00 CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 ❑ CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? YES_NO. IF YES, SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS • ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)?--- YES NO. 4. FULL NAME OF APPLICANT: 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: (P GUzc!�4 B Roa al, OSlewlll e/ 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: _ , r 4 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: LS'gl 10. SOLEOWNER: TES : NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT_ e TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: • COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE Q:\Application Fonns\HAZMAT APP 2017 REVISED. ocx r THE r° Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 BARMASS .. ` 200 Main Street• Hyannis, MA 02601 1639. �i0'FD MP+P`0 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: C,,vJo<--,A^,,Q- fa --, Date: Location/Mai ling Address: I U2B 2 Ds �1l-� Contact Name/Phone: Mx 1fzo - L vReeLOLK- m,4 w, "lA<,G`J Inventory Total mount: ^'� SDS: o License#: Tier II : o Labelin4: S"tkk%\ \� Spill Plan: Oil/Water Separator: o Floor Drains: e -- alu c-1< w p Emer enc Numbers: 6 Storage Areas/Tanks: Lt �o arc Emergency/Containment Equipment: ' v �� r ". %c. Waste Generator ID: A Was a Product: Date&Amount of Last Ship ment/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze 3 Dry cleaning fluids Automatic transmission fluid S Other cleaning solvents&spot removers Z' Engine and radiator flushes Bug and tar removers 3 Hydraulic fluid (including brake fluid) Windshield wash I< 1`k Motor oils 2J Miscellaneous Corrosives '``°`' � Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages 1 Pesticides: t Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners _� Miscellaneous Combustible 2- Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons 2 Laundry soil &stain removers ti (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATION : ORDERS: \2 e-0( 6\x2 g Qtv2 0.Wa� a �e� �o �z e55 . twos Cev INFORMATIO /R COMMENDATIONS: -Vo cX xe—kX— ou 1�0� cGtT�- Q��l�Ql/l S Inspector: I v-,eJ 1e-- Facility Representative WHITE COPY- HEALTH DEPARTMENT/CANARY COPY-BUSINESS IKE►oh8 Town of Barnstable Office:508-862-4644 Public Health Division Fax:508as0-6304 • BARMASSS'. • 200 Main Street• Hyannis, MA 02601 a�. TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: Cvw�a on Date: a S�_11 Location/Mailing Address: it. We 9" IR r ,1 Contact Name/Phone: - 20 - M(,,?) l- w;c Inventory Total Amount: A-4;S a1 MSDS: o CA11 1A, License#: Tier II : o Labeling: Spill Plan: NN )A Oil/WaterSeparator: MIA - Floor Drains: -6 Emergency Numbers: yes Storage Areas/Tanks: Emergency/Containment E uw ment: Waste Generator ID: Waste Product: Date&Amount of Last Shipm nt/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. 10 Antifreeze 1 +I Dry cleaning fluids Automatic transmission fluid q Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers l Hydraulic fluid (including brake fluid) t q Z Windshield wash 3 'Y-7 7-0 Motor oils ;.O Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil i Disinfectants I Miscellaneous petroleum products: Road salts tSo 16 grease, lubricants, gear oil Refrigerants Degreasers for engines&garages t_ Pesticides: t Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners I_ Miscellaneous Combustible 1 -+ ' Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil&stain removers y' (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECO ENDATIONS: o vC2 1 t 5 C.o C. l Inspector. 1I Facility Representative: WHITE COPY- HEALTH DEPARTMENT/CANARY COPY-BUSINESS 3 / �`� TOWN OF BARNSTABLE Date: / [`� n� ,�,oK TOXIC AND HAZARDOUS MATERIALS FORM NAME OF BUSINESS: C,)Ak.O-ek-s Fg-(vks BUSINESS LOCATION: i 11,o Q, 80.V R9 , 06+agLII INVENTORY MAILING ADDRESS: TOTAL AMOUNT- TELEPHONE NUMBER: P$ CONTACT PERSON: l a EMERGENCY CONTACT TEL PHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: 0v04#&w14-N tV— 6` 0cf, - Vko AkS ` 0 4v---V- INFORMATION / RECOMMENDATIONS: o c � ce �� AJa Fire Dlstrict:to% f t CMG o vH Ran�Q�C�o►erg a� �S walZ� CC b-A�m 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 material 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 1 Al freeze (for gasoline or coolant systems) Miscellaneous Corrosive 4NEW 'Ll USED Cesspool cleaners Automatic transmission fluid' ` Disinfectants t Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides t ❑ NEW"' ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous 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 ti Miscellaneous Combustible y Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) 3 Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers �1 Windshield wash 3Sxti WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials 3 Number Fee 1230 THE COMMONWEALTH OF MASSACHUSETTS $50.00 Town of Barnstable 6- Board of Health This is to Certify that Cumberland Farms Store #2269 16 West Bay Road, Osterville, MA Is Hereby Granted a License For: Storing or Handling 26 100 gallons of Hazardous Materials. ----------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2017. unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.KD. 07/01/2016 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health i Town of Barnstable �.: ��► f°,,, g rY Re ulato Services ti Richard V. Scali,Director MAS& Public Health Division BARNSTABLE 1639• `0� "`aw"nmsnw.s�nr�CD�ie nsAY`ue �(.•D •(p r Thomas McKean 39-2014 , Director 16�� 200 Main Street, Hyannis,MA 0260 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT'(RUNS JULY,1st--JUNF30th):"' APPLICATION FEES CATEGORY 1-PERMIT 26— 110 Gallons: $ 50.00 CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 El CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ • A late charge of$10.00 will be assessed if payment is not received by July 1st. ASSESSORS MAP AND PARCEL NO. DATE FULL NAME OF APPLICANT: — , NAME OF ESTABLISHMENT: a�9 — Cumberland Farms ADDRESS OF ESTABLISHMENT! 16 West Bay Road Osterville, MA i MAILING ADDRESS(IF DIFFEREiN I)�/o Coin :- ter, TELEPHONE NUMBER OF ESTABLISHMENT: 'JOB 9f-7 51,'2 3,1 EMAIL ADDRESS: SOLE OWNER: &,&S.' NO IF NO,NAME OF PARTNER: FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER ,'ST CLERK . IF PREPARED BY OUTSIDE PARTY: ' SIGNAT F T Name: . Company Address icrMrd Fournier Telephone#: Tax Manager Email: Q:\Appfication Forms\HAZZAPP Rev I6.docx Page 1 of CumbMand } F A R M 5 Date of Incorporation: September 14, 1984 State of Incorporation: Delaware Principal Address: 100 Crossing Blvd., Framingham, MA 01702 Office Telephone: 508-270-1400 Federal ID No: 04-2843586 PRINCIPAL OFFICERS: Ari N. Haseotes President and CEO 100 Crossing Blvd Framingham, MA 01702 Howard S. Rosenstein Treasurer 100 Crossing Blvd .Framingham, MA 01702 Mark G. Howard Secretary 100 Crossing Blvd Framingham, MA 01702 Brian E. Glennon, II Assistant.Secretary 100 Crossing Blvd. Framingham, MA 01702 John T.Daly Assistant Treasurer 100 Crossing Blvd Framingham, MA 01702 f Town of Barnstable office: 508-862-4644 _ Fax: 508-790-6304 Regulatory Services Department HARNSTABM Public Health Division 'MAWThomas A.McKean,CHO 1e39 ` 200 Main Street, Hyannis, MA 02601- Payment Receipt Hazardous Materials Payment received: $50.00 (Check) on 6/14/2016 I Check number: 393380 Check aMmount: $400.00 - Name on check: Cumberland Farms 'Business: Cumberland Farms #2269 Owner: INC CUMBERLAND FARMS Address: 16 WEST BAY ROAD, Osterville t .... . , r .... JP { SHE T� ASS.M = Town of Barnstable � MASS. Inspectional Services Public Health Division Thomas McKean,Director 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 February 20, 2020 Harry Patel Express Food Mart copy 16 West Bay Road Osterville, MA. 02655 Mr. Patel, Thank you to for your cooperation letting us perform. a.required hazardous materials yearly inspection. This letter contains information from that visit that will help you to become compliant with the Town of Barnstable Ordinance: Chapter 108 Hazardous Materials Enclosed are copies of Chapter 108: Hazardous Material Ordinance and a copy of labeling requirements for all waste products in your shop. I have also enclosed a spill plan/contingency plan that is required. Please note the problems identified at your place of business during the hazardous materials inspection and the corresponding recommendations listed below: PROBLEM: • Material Safety Data Sheets not available during visit. ORDER• • Massachusetts General Law-Right to Know Law states that " MSDS's should be filed in an organized manner at a central location in the workplace so that the employer can easily provide an MSDS if an employee requests one • Town of Barnstable Ordinance Chapter 108: Hazardous Material section 108-4 (B) Inventory and registration states that the "material safety data sheets shall be made available upon request of the Health Department. PROBLEM: • Fire Extinguishers are not recharged to current date and are not readily assessable. o ORDER: • Please have all extinguishes re-charged; assessable, and clearly marked with placard. PROBLEM: • Business license issued from the clerk's office not visible ORDER: . . • Please post current business license PROBLEM: • Spill/Contingency Plan must be posted. ORDER: • Make and post plan, guideline enclosed to make it easier for you PROBLEM: • Spill kit and absorbent pads, speedy dry not readily available ORDER: • Make spill kit and supplies readily available and out in the open PROBLEM: • You do not have a current Hazardous License issued from the Town of Barnstable Health department. ORDER: • Please bring the enclosed license to the Board of Health to obtain a current license Again thank you for your.continued cooperation and I will be back on March 19th, 2020 between 9 AM and 23OPM for a final inspection'report. I realize that the quantity fluctuates during the year and the total may seem high in February, but this quantity reflects the yearly average. - If you have a difference of opinion,please feel free to contact me directly. If you have any questions about the problems, the recommendations, or you need further information, guidance, or assistance, please do not hesitate to contact me directly. j Respectfully, Chester.johnson@town.barnstable.ma.us 508-862-4645 C. Gus Johnson Hazardous Material Specialist DIME Do ti Town of Barnstable Inspectional Services * EARNSTAEIE, + 9 MASS. He alth Division Public Thomas McKean,Director 200 Main Street Hyannis,MA 02601 Phone:508=862-4644 Fax:508-790-6304 Exxon Super Flo Hello 2-13-20 It was nice to see to you today and must say you have a very.clean shop. With a few adjustments as we discussed you will.be in compliance with current regulations. I will be back on 3-10-20 for a final inspection as we agreed. Below are the things we discussed that need immediate attention in your shop to prevent any further action by the Town. 1. You need a waste generator ID number from Mass DEP. A check with them todayreveals that there is none for your location. Each address needs a separate number.( application enclosed) 2. A spill kit is needed for the quantity of products you have on site.Speedy dry, absorbent pads should also be available.( 8-8-19) 3. SDS sheets have to be readily available to employees.As we discussed they.can be obtained from Exxon or on-line. (8-8-19) 4. A spill plan/contingency plan need to be posted and pre-approved by the fire department. Again I left you some blank samples, but are available on line. (8-8-19) 5. ALL containers need to be labeled; Anti-freeze-window washer, both mixed and diluted, waste oil,virgin oil, again these labels are on line, available from Exxon or a supplier similar to Grainger, etc. (8-8-19) - 6. All should be repaired by 3-10-20 for a final inspection (as agreed upon).Your currerif license from the Board of Health is good until July 2020 7. Check with the Town Clerks office and make sure your business license is valid;these are good for 4 years. 8. We will work with you in any we can to help you and your business. BUT enclosed is a-copy . of what was asked and agreed on by you to be completed back on 8-8-19.The aforementioned have to be completed by 3-10-20 to prevent further action by the Town. I feel that 6 Months is sufficient warning of violations. Highlighted areas on 8-8-19 sheet show the aforementioned Respectfully, ' ' C.Gus Johnson Hazardous Materials Inspector Chester.iohnson@town.barnstable.ma.us 508-862-4645 Hayden Building Movers .1-24-2020 Bob it was nice to meet with you today. Also very nice was the amount of cleanup of debris and waste that was done outside the building in such a short time. I will make a list of things' that need addressing at your business to bring you within guidelines for both health and safety: Below is a list of what needs immediate attention: 1. The 275 gallon drum used for heating the building needs a couple of things, I have included a copy of Chapter 326 with the guidelines for Fuel storage tanks a. It needs to be ruistproofed b. It need a concrete pad under tank 2.' The 55 gallon drum with waste oil be moved inside 3. Move and empty the plastic drum that contains water in it . 4. All of the containers that hold new and or waste must be marked appropriately, again I have included the rules for these markings for you to use as a guideline. You fall under a. very small generator VSQG from the Mass DEP, included 5. Verify a business license for your business with the Town clerk's office 508-862-4044 6. Mark steel cabinets as described in guideline attached, Flammable 7. All egresses must be marked 8. If possible you could obtain a spill kit and an eyewash station for your business 9. Spill and contingency plan , attached sample for you must be posted 10. 1 also have included for you a check list that we use to help us navigate different businesses in Town. Just for you to look at Again thank you for your cooperation and as we discussed you felt February 25, 2020 would a completion date for the aforementioned and a walk thru done by you and me at this time. I will call you on or about the 25th. If you need more time or any questions or concerns, please do not hesitate to contact me. Respectfully C. Gus Johnson Hazardous Material Inspector Town of Barnstable Health 508-862-4645 chester.johnson@town.barnstable.ma.us r Land or Sea is in the acquisition of another work space at 381 Old Falmouth Road. They are in unit 10 for office needs and newly acquired unit 43 to be used for work. I°met with the owner Ken today to give him some guidance on HAZ MAT which will be in the area of at least 200+ gallons of muriatic acid stripping liquids and the stripping tanks for the acid to be used. He will be in transition and we agreed on a.date on March 3`d to contact and see if he is readyfor an inspection by us. I gave him paperwork to assist him along and he was very cooperative in this matter. I was pretty strong on what he will need such as an eye wash station and proper marking on products, etc.. He is very cooperative in this matter, Gus 1-28-20 U I copy Y •. didn't know if you wanted to update this for now. I did supply him with haz-mat new business form oFz r Town of Barnstable ti RAPN&rA MASS Inspectional Services �F Public Health Division Thomas McKean, Director 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Rotary Collision Center 2-28-20 John, , As discussed this is the letter that has all the information you need to comply with the regulations. Things that need to be fixed are as follows: 1. Contingency plan needs to be posted 2. Spill plan needs to be posted ' 3. All waste drums MUST be marked 4. All hazardous waste must be removed ASAP copy 5. Paint and flammable storage rooms must be so marked 6. Spill Kit must be made available 7. 55 Gallon drum seal coat must be removed if not used ASAP I realize that you are away until April 1, 2020 so if we could plan a checkup date of APRIL 15, 2020 it would be great. As we discussed enclosed is a list of things we talked about to make it a little easier for you. If you have someone lookup the following rules, it will give a guide to follow to become compliant. Town of Barnstable web site, click on a-code for Chapter i08, 326.Or just search for hazardous waste storage/disposal, etc. Mass general laws 310CMR 30 will assist you in storage drums and containers PLEASE HAVE THESE THINGS FIXED ASAP,AS I WILL BE BACK THE WEEK OF APRIL 15TH I know that this is time consuming but it must be done ASAP. Remember what we discussed about Mass D.E.P and OSHA for fines. They will respond;to any complaints that they may receive. If you need anything at all please call me.Thanks for your cooperation I have enclosed my business card with contact information C. Gus Johnson Hazardous Materials Specialist 1-30-20 West End Auto Revival 27 Bettys Pond Road (Hello; it was a pleasure to meet you guys today and I must say that your shop is very neat and clean As we discussed: 1. 1 left several blank sheets that need-to be filled out and a DEP contact sheet for obtaining a generator of hazardous waste number. There is no cost for this, BUT you need one even if you use waste oil for heat at building. No company can pick up waste products without this number. 2. A spill plan and contingency plan need to be displayed in store 3. All waste products must be clearly marked as such 4. For your own protection, all floor drainsshould be documented,by you, showing drain, date, etc. Especially`if you do not own property. 5. All rules about safely storing and using any hazardous material are available on our-web site and/or the Mass DEP. 6. MSDS Sheets need to be available 7. Spill kits/speedy dry available for any spills that me happen . r Just a few things that need to be addressed and I will check back with you for completion the first week of March Any questions or concerns, please feel free to contact me directly. C. Gus Johnson Hazardous Materials Inspector Town of Barnstable Board of Health 508-862-4645 chester.johnson@town.barnstable.ma.us Rey N SMEAPD v�'IINC VIM QRCAKII7r.n NO. 1033A 2-153L MADE IN USA aF T rll7,ANIZED AT SMEQD.CnU