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HomeMy WebLinkAbout0180 FALMOUTH ROAD/RTE 28 - Health 180 Falmouth Rd., Hyannis 71 r f i II TOXIC AND HAZARDOUS MATERIALS RE ZSTRATION FORM FAMILY HAIRCUT STORE Mail To: NAME OF BUSINESS: 180 FALMOUTH ROAD Board of Health MAILING ADDRESS: Town of Barnstable TELEPHONE NUMBER: 6 P.O. Box 534 CONTACT PERSON: I '-W IH b—=1GIV Hyannis, MA 02601 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalli�g, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES — NO . This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous characteristics and must be registered v+ ur� stotallIkangtad t. Please put a check beside each product that you store: Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business i Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: BUSINESS LOCATION:/ eaD E4Lw-OW 40,A o�lyl, ' n16P) MAILINGADDRESS: 5 -d Mail To: TELEPHONE NUMBER: cf d Board of Health CONTACTPERSON: TAMC1.5 40615 Town of Barnstable P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: SW Hyannis, MA 02601 TYPEOFBUSINESS: ,4Io.)) _4 L&!� Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(forgasoline orcoolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW � USED (insecticides, herbicides, rodenticides) Gasoline, Jet ruel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) - lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers S APaints, varnishes, stains, dyes PCB's La,gquer thinners Other chlorinated hydrocarbons, NEW USED inc. carbon tetrachloride Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) qe Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Nv TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair BOARD OF HEALTH satisfactory 2.Printers 3.Auto Body Shops unsatisfactory- 4.Manufacturers �� -&9 (see"Orders") 5.Retail Stores COMPANY^ pop� 6.Fuel Suppliers ADDRESS �ZO /��f � Cl SS: 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS / ,. - , Tanks IN OUT IN I OUTI IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil(C) transmission/hydraulic Synthetic Organics: degreasers x dam � Mis ellaneous: 1 C ; u 1111 % DISPOSALIRECLAMATION REMARKS: 1. Sanitary Sewage 2. ater Supply S-4 xr, Town Sewer Public On-site A——Public 3. Indoor Floor Drains YES NO. O Holding tank: MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES—,2(NoORDERS: O Holding tank:MDC °Catch basin/Dry well O On-site system 5.Waste Transporter 1 • ' � �uc NO 2 J MLI _�X"f4 A/d ( Person (s) Interviewed Inspe for �' Date TOWN OF BARNSTABLE LOCATION </94W SEWAGE # VIL-LAGE' ASSESSOR'S MAP & LOT,3//— DU/ INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY e —21" f LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WE��Oi R PUBLIC WATER BUILDER OR OWNER 2A DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No -� `� �- ��'/' f_ � ��. ® A� �. � _ _ \ '� No.. FRic '.....�_._. ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r. ----- .OF..... Applirafiou for Disposal Works Toustrurtion rumit Application is hereby made for a Permit to Construct ( ) or Repair (0<) an Individual Sewage Disposal System at: ----- - ,.t t -------------------------------------------- o n,Address t No. Owner /V/(/ Adds c- a •---- -------------•- --• -- �Re'��'�5(=C.:_.����^=-•-='S.....-•-----........-- --�.-----�-------•----- .!`.....----.:........---..................... -•--- Installer Address d Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a, Other—Type of Building `............. No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ xDisposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit___-____---_-._____. Depth to ground water•-_-------___________-:- G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------------------------- --------- •........ •... .-.---- -........ ------ ---•-•........ ---------------- -------•------ ----... ------------------------------------ ODescription of Soil------------------------------•-------------------......------...-------------------------------------------------•-------------------------------•---..............-- x U ............................................................---•-----•---•----•-•••••----•-••-----•--•--...--•--•--•-•••--•••--•-••-•---••-•----•-••----•----••------••••-••-......•--•-••-•••---••••••. x ------------------------------------------------------------------------------------------------------------- --------- ----•---•- ............................................... V Nature of Repairs or Altera •o ..—Answer when appli ble... ____/ 4 ^ ---•-------• -----••••••-------•----...•-•-•-••••----••-•-•••••.............•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T` i. p of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee iss ed by the bo d of health. Signed t Date Application Approved By--••--•--• ,•�-a . . --------•-•----•-------•--------- --------. .... 0.... >1 Date Application Disapproved for the following reasons---------------------------------------------•-•------------------------------------------------•......••--.----- -------•--•-.....----•-------•--------------•-----------------------------•----------..........----------'---------------•-----------------------------------------------•------------------------------- Date PermitNo. ........... :L......----••.... Issued....................................................... TOWN OF BARNSTABLE LOCATION /6� SEWAGE # VILLAGE- �� ASSESSOR'S MAP LOT,3//— 00S INSTALLER'S NAME & PHONE NO. r zz y; SEPTIC TANK CAPACITYDIJO LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WE , OR PUBLIC WATE_k� BUILDER OR OWNER DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No l I f No..ji.t...�ht_ FEE.....L ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD O-F HEALTH ..........._OF....... ----------------------------------------- Aplifiration for Uhipaaal Vorkfi Tonstrurtion Punfit Application is hereby made for a Permit to Construct or Repair O an Individual Sewage Disposal System at: ...................................................... ---------- i.w Address N or................................................................ .......... ..... ------------------------------------- Add ;7 ...61.uow n e r .. Installer Address Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder �_l 04 Other—Type of Building kz4�.r............. No. of persons............................ Showers Cafeteria 04 Other fixtures ..................................................................................................................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid capacity............gallons Length................ Width..............._ Diameter_.........___._. Depth..:...._........ Disposal Trench—NTo. .................... Width.................... Total Length__......_._......... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter----___.-_-_--_____- Depth below inlet......._........._,. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( 1) 11� Percolation Test Results Performed by......................................................7................... Date........................................ a Test Pit No. I_------------_-minutes per inch Depth of Test Pit.................... Depth to ground water_.--__---____________-_. rLf Test Pit No. 2................minutes per inch Depth of Test Pit............._._.... Depth to ground water------------------------ P4 ............................................................................................................................................................ 0 Description of Soil.............................................................I........................................................................................................... x U ......................................................................................................................................................................................................... ----------------------------------------------------------------------------------------------------------------- ................ U Natuye of Repairs or AlteraPioons—Answer when applicable...C-.ee_4k4------A�®©___ .. ----W..... ... ................... ----------------------------- ...................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT 1.h, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been; ied by the board of health. Signed.. --------------------- ...... Date Application Approved By............ -zn...... ....4__w6e-i�................................. ........//::./Z._.- F; a K7 . -i Date Application Disapproved for the following reasons:.............................................................................................................. ...................................................................................................................................................................................................... Date PermitNo._-----..?-.q----- ................. Issued....................................................... Da- sl THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... .............OF......�-.-4i�e'-t ....................................... ................__ T-5rdifiratr of Toutpliatta THIS IS TO CERTIFY,jhat the Individual Sewaw Disposal System constructed or Repaired_ e by . ............. .... ............................ ........................................................................................ at.......... .................. ------ . .................................................................... has been installed in accordance with the provisions of TIT'11-4- 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.--__-_- dated.....__.. ..................................... THE ISSUANCE OF THIS-CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL Fl . UNCTION SATISFACTORY. DATE........22.- 7 ............. Inspect 1_:P'�101------------ .............................. ...............7..............------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............OF_4­-e.. ....... . ........................................ No...O./:. .A_:).. FEE. __nrunt iar_ ............... Permission is hereby granted............C�........................ ---- ........................................ to, Construct or Repair (N-) an Individual Sewage Disposa e" Syst a, No..............j Z --------------/a..... .. ....................... ................... I" Sweet --as shown on the application for Disposal Works Construction Permit No.g!�.--- Dated.......................................... ................................ ...L- ----------------------------------------------------- Board of Health .........DATE...................Ii. - �1�.. ....................................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS