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3778 FALMOUTH ROAD/RTE 28 - Health
3778 Falmouth -o Gt-cl OHN-LAW s a FUN d .' OME D - -- _ - - -- - - - r� ti i s P �l :1 P� Commonwealth of Massachusetts Title 5 Official Inspection Form' p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is Marstons Mills MA 02648 November 4 2011 required for , every 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 A. General Information 9' forms on the computer,use 1. Inspector: only the tab key I 1 to move your Patrick M. O'Connell cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA C,—:;Q2648 City/Town State "Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification i certify that I have personally inspected the sewage disposal system at this address and that ttR :ZI 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 F!Tther Eva!!cation by the Local Approving Authority November 4, 2011 Job# 11-199 _ In ector'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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the 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. !Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Di osal System• age 1 of 17 r \ Commonwealth of Massachusetts Title 5 Official Inspection Form s . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: g I have not found any information which indicates that any of the failure criteria described in 310 CMk 15.303 or in 310 CIVIR 15.304 exist. Any faiiure criteria not evaluated are indicated below. . Comments: Tank was not in need of pumping at time of inspection. One leaching pit had 3' of standing water and other had 4'of standing water. 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 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 tang; is replaced wiIh a.C.,mnlvinn seotic 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 ❑ N ❑ 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 ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ 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: I� ❑ 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments µ 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is Marstons Mills required wired for MA 02648 November 4, 2011 every 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 10.0 feet of a,surface water supp!y;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 50 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 or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins-11110 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 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 wa ter elevation. ❑ ® 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.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of V f Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every page. Cityrrown 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? ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Unknown Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•11/10 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 �M 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter headings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2 years ago.Date Commercial/Industrial Flow Conditions: Type of Establishment: Funeral Home N/A no design criteria for funeral homes Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ® Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: N/A Irrigation system. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Currently in use. Date Other(describe below): General Information Pumping Records: Source of information: Septic tank pumped annually Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 8 feet Material of construction: ❑cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 8'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: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 2 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 ". .;< Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every 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 27 Scum thickness 2" 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 12" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert tees were intact. Grease Trap (locate on site plan): Depth below grade: feet Material of.construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 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 Date of last pumping: Date l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: 2' Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Unknown, paved over Capacity: gallons Design Flow: N/Agallons per day Alarm present: ® Yes ❑ No Alarm level: 3/5 Alarm in working order: ® Yes ❑ No Date of last pumping: Unknown, pumped every 2-3 months. Date Comments (condition of alarm and float switches, etc.): Tank was structurally sound and alarm float was in place. *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ® No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 • : ; Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every page. Cityrrown 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 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.): 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface _Sewage Disposal System Form Not for Voluntary Assessments �M 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two 6x6 pits. ❑ 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.): Leaching pit#1 had 3' of standing water and#2 had 4' of standing water. No high stains or evidence of surcharge was found on either pit. Cesspools (cesspool myst 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 t5ins•11/10 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 r 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name informationis Marstons Mills required wir for for MA 02648 November 4, 2011 every page. Cityfrown 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 30+ 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: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 25 and topo map shows property at el. 60. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3778 Falmouth Road Property Address Lawrence Bennett-John Lawrence Funeral Home Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2011 every page. Citylfown 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 . ,� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3778 Falmouth Road — ------...-----.....--..._.......... Property Address Lawrence Bennett - John Lawrence Funeral Home Owner Owner's Name -----------._......._.._---------------__ ------------------- information is Marstons Mills 02648 required for --------._- MA November 4, 2011---------..-.- _ every 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 Falmouth Road / / / / / ! r / f / / / / J / J I•+ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ / r \ \ ♦ ♦ \ \ \ ♦ \ \ ♦ ♦ . . . . . . . . . . . . . . . . . . .. . . . -Q, Edge of pav ent CA covers at grade Page 2 of 2 Sent: Monday,June 07,2010 10:14 AM To: Hill, Dana(DEP) Subject: RE: Barnstable DEPOls Hi,Dana, ' This is the only one in my record: 2160 Meeting House Way,West X224393 I West Barnstable Fire Dept. Barnstable 02668 508-362-3241 SE BRP 10/22/2008 Ming 6/14/2010 TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1. Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH O 3.Auto Body Shops unsatisfactory- 4.Manufacturers COMPANY)d4I—bgWP,aZE Tyto (see"Orders") 5.Retail Stores ' �,�,,a� 6.Fuel Suppliers ADDRESS 25�R {�AIMCOS� d)• "_ V1ass: 7.Miscellaneous QUANTITIES AND STORAGE (IN= indoors; OUT=outdoors) MAJOR MATERIALS 1-)rums -inks UndergroundTank S IN OUT IN OUT IN OUT #&gallons Age Test Fuels: PO-1 (B) HVM7'eifs. S414 waste mo 0 a3e:v�etcr a;t �l`1 is degxeasers— Misgellaneous: ILO oZ 7 iDttl S _ Cp O. I , !i ri FtkM-OL- AVj o9 ILL DISPOSALIRECLAMATION REMARKS: 1. Sanitary Sewage W Ater Supply Nl36 � �P1 O Town Sewer blic On-site OPrivate . Indoor Floor Drains YES N04 O Holding tank:MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO ORDERS: -- O Holding tank:MDC O Catch basin/Dry well _ — I o(D O On-site system 5.Waste Transporter 2. Cal N a o Grp� � ► a Person(s)Interviewed Inspector Date i JOHN-LAWRENOE TEL.(508)428-5704 II FUNERAL HOME 3778 FALMOUTU ROAD ROUTE 28 MARSTONS MILLS,MASS.02W LARRY Lawrence J.Bennett TOWN OF BARNSTABLE C MPLIANCE: CLASS: 1.Marine,Gas Stations,R pair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops O unsatisfactory- 4.Manufacturers COMPANY�4V_40_e_�� (see"Orders") 5.Retail Stores !� � 6.Fuel Suppliers ADDRESS � �OY�.�� �Class: 7.Miscellaneous QUANTITIES AND STORAGE (IN= indoors; OUT=outdoors) MAJOR MATERIALS Case lots Drums Above tanks Underground Tanks IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline Jet Fuel(A) Diesel, Kerosene, #2 (B) Heavy Oils: waste� lam'tvP-u ) a"3 new mdtor of V(C4 transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: � I DISPOSAURECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply 0 Town Sewer Public )�fOn-site OPrivate 3. Indoor Floor Drains YES NO IY 0 Holding tank:MDC_ 0 Catch basin/Dry well 0 On-site system 4. Outdoor Surface drains:YESLZNO ORDERS: 0 Holding tank:MDC tatch basin/Dry well n-site system 5.Waste Transporter Name of Hauler Destination Waste Product 2. I Person s) Interviewed nspector Date I TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: John-Lawrence Funeral Home Mail To: BUSINESS LOCATION: 3778 Falmouth Rd. Marstons Mills , Ma. Board of Health Town of Barnstable MAILING ADDRESS: PO Box 10 , Marstons Mills , Ma. 02648 P.O. Box534 TELEPHONE NUMBER: ( 508 ) 428-5704 Hyannis, MA 02601 CONTACT PERSON: Lawrence J. Bennett EMERGENCY CONTACT TELEPHONE NUMBER: 428-5704 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO xx This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store: Quantity/Case Quantity/Case Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) XX See attached sheets for Other cleaning solvents info & ouanities . Bug and tar removers Household cleansers, oven cleaners White Copy- Health Department/ Canary Copy-Business y THE DODGE COMPANY, INC. HAZARD RATING: Fire 165 Cambridge Park Drive 4 - EXTREME 2 Reactivity Cambridge, MA 02140 . HIGH 617-661-0500 2 0 2 - MODERATE Helm 1 - SLIGHT 0 0 - NO HAZARD Special MATERIAL SAFETY DATA SHEET I. PRODUCT IDENTIFICATION: Class: Arterial Embalming Chemical -Trade Name: CHROMATECH DOT Hazard classification: Formaldehyde Solution, UN #2209 Class 9 11. HAZARDOUS INGREDIENTS: Chemical Identity, Common Name(S) CAS No. Wt. % Exposure Limits Formaldehyde 50-00-0 20 . 5 0 .15 ppm (OSHA TWA) 2 ppm (OSHA STEL) Potential cancer Hazard (NTP, IARC, OSHA) Methanol 67-56-1 8 . 0 200 ppm (OSHA TWA) (ACGIH TLV&TWA- includes skin ) III. PHYSICAL DATA: Boiling Point (OF.) 204-214 Specific Gravity (H20=1) 1.055-1.065 Vapor Pressure (mm Hg) unkn Percent Volatile (by volume) 93 Vapor Density (Air=1) 1 Evaporation Rate (Bu Acetate=l) partial> 1 Solubility in Water complet pH� 7 , 5-9 ,o Appearance and Odor: deep red clear liquid, slightly perfumed , 'pungent odor IV. FIRE AND EXPLOSION HAZARD DATA: Flammable Limits in Air: 7 a - 739. Flash Point: 18 3 of (TOC ) Extinguishing Media: Water Spray, Foam, Dry Chemical, Carbon Dioxide. Special Fire Fighting Procedures: Wear self-contained breathing apparatus (SCBA) and calplete personal protective a ui Amen t P q . Unusual Fire and Explosion Hazards: None. Avoid water streams (vs: spray) which may splash and spread flaming liquid. V. REACTIVITY DATA: S Stability: Unstable Conditions to Avoid: Exposure to• Cold.may cause Stable X precipitationtiof the polymers, Incompatibility: which will redissolve slowly Avoid contact with strong on heating. (materials t0 avoid) alkalies, strong mineral acids. .. r Hazardous Decomposition te_ •A,.._ - Pro�u, s: Maji form formaldehyde gas; carbon dioxide, carbon Hazardous Polymerization, May_occur monoxide, various hydrocarbons, Will not occur X VI. HEALTH HAZARD DATA: Primary routes of entry: Inhalation, Skin HAZARD IDENTIFICATION: EMERGENCY and FIRST AID PROCEDURES: 1. INHALATION: Highly irritating 1. INHALATION: Remove patient from to•upper respiratory tract. May contaminated area. If breathing has cause inflammation to lining of stopped, give artificial respiration nose, throat, and lungs, with followed by oxygen, if needed. Keep bronchopneumonia and edema pos- warm and quiet. Call a physician. sible from extremely irritating exposure. 2. 'SKIN: Contact with liquid causes 2. SKIN: Remove contaminated clothing. drying, cracking, and .scaling. Pro- Wash skin well with large amounts longed and repeated contact causes of water. If irritation persists, a hardening or tanning effect. May contact a physician. cause contact allergic dermatitis. 3. EYE CONTACT: Exposure to high 3. EYE CONTACT: Flush eyes with water vapor concentrations or contact for at least 15 minutes. Contact a with liquid causes tearing and physician immediately. severe irritation. Contact with : liquid causes severe burns. 4 . INGESTION: Poisonous if swallowed. 4 . INGESTION: Induce vomiting imme-di- Causes severe irritation to mouth, ately by giving 2 glasses of water throat, and stomach. Severe and pressing finger down the throat, stomach pains will follow with applying this technique only if the possible loss of consciousness. person is conscious. Contact a Blindness or death may occur. physician immediately. VII. SAFE HANDLING and USE: Spill Procedures: Eliminate ignition sources, neutralize with diluted solutions of ammonia or sodium sulfite. Soak up with noncombustible absorbent material, remove and allow to dry in a well venti- lated area. Flush wiped area with water. Waste Disposal: Improper disposal can cause damage to the environment. Consult with local environmental authorities for guidance before disposing. VIII. SPECIAL PROTECTION INFORMATION: Respiratory Protection: Use NIOSH/MSHA approved equipment. A full face shield/goggles combination or appropriate respirator should be used if exposure limits are exceeded. .See Table I, 29 CFR -1919.1048g. I Protective Gloves: Rubber, Neoprene, Nitrile, or other waterproof gloves. Eye Protection: Safety goggles for normal use. Ventilation: Natural or mechanical local exhaust, if necessary. Keep TLV within limits. IX.. SPECIAL PRECAUTIONS: Handling and Storing: Avoid contact with eyes, skin, clothing. Avoid prolonged breathing of vapor. Do not store for long periods of time below 350F, or above 1100F. Keep containers tightly closed when not in use. Wash thoroughly after handling. . This information is furnished without warranty, representation, or license of any kind, except that it is accurate to the best of The Dodge Chemical Company's knowledge or obtained from sources believed by The Dodge Chemical Company to be accurate. The Dodge Chemical Company does not assume any responsibilities for use_ or reliance upon same. Customers are encouraged to conduct their own tests..r��a using"; - `Product, read the label. Revision Date: November 1992 HAZARD RATING: Fire 4 - EXTREME The Dodge Chemical Company 1 Reactivity 165 Cambridge Park Drive 3 - HIGH 0 0 Post Office Box 193 2 - MODERATE Health Cambridge, MA 02140-0193 1 - SLIGHT 0 617-661-0500 0 - NO HAZARD Special MATERIAL SAFETY DATA SHEET I. PRODUCT IDENTIFICATION: a` Class: Color concentrate, Mixture -.Trade Name: ICTERINE, (All colors : Regular., Peach, Suntan) DOT Hazard classification: ORM D II. HAZARDOUS INGREDIENTS: Chemical Identity, Common Name(s) CAS No. Wt. % Exposure Limits Alcohol: Isopropanol, Isopropyl 67-63-0 1.3 400ppm (OSHA TWA) Alcohol, Dimethylcarbinol, 400ppm (ACGIH TWA) Rubbing Alcohol III. PHYSICAL DATA: Boilirfgoint (°F) >22o Specific Gravity (H2O=1) 1.03-1.04 Vapor Pressure (mm Hg) 0.07 Percent Volatile (by volume) 98 Vapor Density (Air=1) >1 Evaporation Rate (Bu Acetate=1) c 1 Solubility in Water Complete pH N.A. Appearance and Odor: slightly viscous liquid, odorless. color range: Deep-red, orange-red with slight fluorescence, red-brown. IV. FIRE AND EXPLOSION HAZARD.DATA: Flammable Limits in Air: 2.6% - 12.5%' Flash Point: 2200 F (TCC) Extinguishing Media: If involved in fire use Carbon Dioxide, Foam, °r Dry ctuca�' Special.Fire Fighting Procedures: Wear self-contained breathing apparatus (SCBA) with . : Unusual Fire and Explosion Hazards: a full face piece operated in a positive pressure mode when fighting fires. None. V. REACTIVITY DATA: Stability.: Unstable Conditions to Avoid: Avoid contact with open flame. Stable x Incompatibility: Avoid contact with strong M (materials to avoid) . oxidiZe.rs. 3. ... Hazardous Decomposition Products �he ►na1 de�om�ostion ma}� form Carbon Dioxide, ar aA.:Mon xi a.:. Hazardous Polymerization: Ma .occur Will not occur. x VI. HEALTH HAZARD DATA: Primary routes of entry: Innalation, 5ki11 Contact. HAZARD IDENTIFICATION: EMERGENCY and FIRST AID PROCEDURES: 1.; INHALATION: Can cause dizziness, 1. INHALATION: Remove person from nausea, visual impairmient, res- contaminated area to fresh air. If piratory failure, muscular breathing is difficult, administer incoordination,: and narcosis. oxygen, if breathing has stopped, give artificial respiration. Call a physician. 2. 'SKIN: Contact causes irritation, 2. SKIN: Wash area thoroughly with soap dryness, redness, dermatitis. and water. Remove contaminated clothing. Launder before re-use. If irritation persists, contact a physician. 3. EYE CONTACT: Exposure to high 3. EYE CONTACT: Flush with large amounts vapor concentrations, or contact of water for 15 minutes. Contact a with liquid causes redness and physician. irritation. 3. INGESTION: Causes irritation of 4. INGESTION: If conscious, drink large the gastrointestinal tract, amounts of water, milk or sodium bi- abdominal pain, diarrhea, dizzi- carbonate to dilute material in ness, headache, and blindness. stomach. Induce vomiting by placing Cannot be made non-poisonous: finger in back of throat. Contact a physician immediately. r VII. SAFE HANDLING and USE: Spill Procedures: Eliminate all ignition sources. Use absorbent material to soak up spilled material. Allow to dry in a well ventilated area. Waste Disposal: Dispose of dried material in accordance with local, state, and federal regulations. Vill. SPECIAL PROTECTION INFORMATION: Respiratory Protection: If ventilation inadequate, use NIOSH/MSHA approved respirators. Protective Gloves: Rubber or other waterproof gloves,recommended. Eye Protection: Safety goggles recommended. Ventilation: Yes. Natural, or mechanical, local exhaust if necessary to keep TLV within"limits. IX. SPECIAL PRECAUTIONS: Handling and Stdring: 'Avoid °prolonged or repeated breathing.of vapor. Avoid contact with eyes, skin, and clothing. Wash thoroughly after handling and before.eating, drinking, or smoking. .. ' Other: Store in closed containers in cool place. Do not smoke in areas of use or storage. This information is furnished without.warranty, representation, or license of airy kind, except that it is accurate to the best of The Dodge ,Chemical Company's knowledge or.obtained from sources believed by The:,Dodge Chemical Company to be accurate.irhe Dodge Chemical Company does not assume any.responsibilities for use or reliance upon same. Customers are encouraged *.to'conduct the.ir�,own tests. Before using any product, read the label. Revision. Date: J arua�'y .�19 9 2 . ` HAZARD RATING: Fire The Dodge Chemlcal Company 4 a EXTREME 2 Reactivity 165 Cambridge Park Drive 3 - HIGH 2 10 Post Ot1iCe Box 193 2 • MODERATE Ca mbrid e, MA 02140-0193 Health 9 O 1 . SLIGHT 617�61.0500 Special , 0 - NO HAZARD MATERIAL SAFETY DATA SHEET I. PRODUCT IDENTIFICATION: Class; Arterial Embalming Chemical, Mixture Trade Name: INTROFIANT D.C. DOT Hazard classification: ORM-A UN 2209 II. HAZARDOUS INGREDIENTS: Chemical Identity, Common Name(s) CAS No. Wt. % Exposure Limits Aldehyde : Methylene Glycol 50-00-0 27.5 1 ppm (OSHA TWA) Formaldehyde 2 ppm (OSHA STEL) Methylene Oxide * Potential cancer Oxymethylene Hazard .( NTP, IAR( OSHA) Alcohol:, Methanol, Carbinol 67-56-1 8.0 200ppm (OSHA TWA) Wood Alcohol (ACGIH TLV 6 TWA) (ACGIH includes skin; III. PHYSICAL DATA: Boiling Point (OF.) 204-214 Specific Gravity (H2O=1) 1.08-109 Vapor Pressure (mm Hg) unkn Percent Volatile (by volume) 96 Vapor Density (Air=1) > 1 Evaporation Rate (Bu Acetate=1) Partial > 1 Solubility in Water I Complete I pH 8-8.5 Appearance and Odor: Clear, deep garnet-red• liquid;- pungent odor FIR .E AND. EXPLOSION HAZARD DATA: Flammable.;Limits in Air: 7% 73%' Flash Point: 198° F (TOC) , . Extinguishing Media: Water Spray,., Foam, Dry Chemical, Carbon Dioxide Special Firefighting. Procedures: Wear self-contained breathing apparatus (SCBA) ant complete personal protective equipment. YUnusual Fire and Explosion Hazards: No ye. Avoid water streams (vs spray) which may ;spy 1q sp ash and spread flaming liquid. i g hwi S V ' TIFTY DATA ; r� k t 1 tUnstable Exposure to col may cause 4% Conditions to Avoid:`V ,Nw precipitation o the po ym rs, � � i,y :. which will redissolve slowly « 'Sable ?�.: " ,.. on heating. g frtCom 3tiat J(y. Avoid eantact with strong;'` 4 alkalies, stl,ong,ctineral A. at ts acids. �m [i ,:. e,. ;;tar;avc�id� • . IazardousQecomposition Products .max form formaldehyde gas carbon dioxide, i ,. •r car on-monoxide, various < ydrocarbons. Haza�c�Qu "poi yme4zation:. Ma occur f . Will.not: occur x VI. HEALTH HAZARD DATA: Primary routes of entry: Inhalation, Skin HAZARD IDENTIFICATION: EMERGENCY and FIRST AID PROCEDURES: 1 INHALATION: Highly irritating 1. INHALATION: Remove patient from to-upper respiratory tract. May contaminated area. If breathing has cause inflammation to lining of stopped, give artificial respiration nose, throat, .and lungs, with followed by oxygen, if needed. Keep bronchopneumonia and edema pos- warm and quiet. Call a physician. sible from extremely irritating exposure. 1 . . 2. SKIN: Contact with liquid causes 2 SKIN: Remove contaminated clothing. drying, cracking, and scaling. Pro- Wash skin well with large amounts longed„and .repeated contact, causes of water. If irritation persists, a hardening or tanning effect. May contact a physician. cause contact allergic dermatitis. 3. EYE CONTACT: Exposure to high 3• EYE CONTACT: Flush eyes with water vapor concentrations or contact for at least 15 minutes. Contact a with liquid causes tearing and physician immediately. severe irritation. Contact with liquid causes severe burns. 4 . INGESTION: Poisonous if swallowed. 4 . INGESTION: Induce vomiting immedi- ately by giving 2 glasses of water throat, and stomach. Severe and pressing finger down the throat, stomach pains will follow with applying this technique only if the possible loss of consciousness. person is -conscious. Contact a Blindness or death may; occur. physician immediately. VII. SAFE HANDLING and USE: Spill Procedures: Eliminate ignition sources, neutralize with diluted solutions of ammonia or sodium sulfite. Soak up with noncombustible ' absorbent material, remove and allow to dry in a well venti- lated area. Flush wiped area with water. Waste Disposal: Dispose of dried material in accordance with Federal, State, and local regulations. VIII. SPECIAL PROTECTION INFORMATION: Respiratory Protection: Use NIOSH/MSHA approved equipment. A full face shield/goggles combination or appropriate respirator should be used if exposure limits are exceeded. See Table I, 29 CFR 1919.1048g. Protective Gloves: Rubber, Neoprene, Nitrile, or other waterproof gloves.. . <{"` Eye Protection: Safety goggles for normal use. Ventilation: Natural or mechanical local exhaust, if. necessary. Keep. TLV within limits. IX. SPECIAL PRECAUTIONS: Handling and Storing: Avoid contact with eyes, skin, clothing. Avoid prolonged breathing of vapor. Do not�-store. for .long periods of �t�ne�r below 350F, or above 1100F. Keep'conta.ners tightlyCS when not in use. Wash thoroughly� after,handling. This information is furnished without warranty,'rep,resentation,.or, I;icense.of,angdsexcept' P.; that it is accurate to the best of. The Dodg9 Chami,cal Company's knowledge tamed from >° : sources believed The:_Dod a Chemical Com any to be accurate. The Dod Chemical ; Y 9 p _ 9� ; Company does not as any responsibilities (or use:.Or;,reliance upony'same� Cu$to.m are encouraged to conduct their own ,tests,:.Be(ore. using any. product, r©aciha, label •:s "Revision Date: February 1991 {; Q MNIERIAL SAFETY DATA SHEE Page 1 of 2 Revised: 04/23/93 I. PRC Trade Name.....................: P E R M A F I X �q llo �. S Class..........................: Cavity Embalming Chemical, Mixture DOT/W Hazard Classification...: Formaldehyde Solution, 9, UN 2209, PG III Manufacturer: The Dodge Company, Inc. Hazard Rating: FIRE......... 2 4 = Extreme 165 Cambridge Park Dr. HEMM....... 3 3.= High P. O. Box 193 IaMCTIVII'Y .. 0 2 = Moderate Cambridge, MA 02140 SQL...... 0 1 = Slight (617) 661-0500 0 = No Hazard II. HAZAIWOUS INMMIERrS: common Mwe Cl cal F3mm ly CAS# Wt% Exposure Limit Foonaldehyde Aldehyde 50-00-0 21.5 0.75 ppm (CSHA TWA) 2 ppm (OSfiA SrM) Potential Cancer Hazard (NII'P, IARC, CSHA) Methanol or Alcohol 67-56-1 13.5 200 ppm (OSHA TWA and ACGIH TLV-ma*) Methyl Alcohol * includes skin i M. PHYSIM DAM: a Boiling Point ('F)......: 199-214. Specific Goavity (H20=1)........: 1.044-1.054 Vapor Pressure (mm Hg)..: Unknown Percent Volatile (by volume)....: 98 Vapor Density (Air=1)...: Greater than 1 Evaporation Rate (Bu Acetate=U.: Less than 1 Solubility in Water.....: Complete pH..............................: 5.9-7 Appearance and Odor: Clear, straw-colored liquid; slightly perfumed, samewk-at pungent odor. IV. FIRE AMID HAZARD DATA: Flammable Limits in Air: 7%-73%* Flash Paint: 1690F (ZCC) *For solutions of 37% formaldehyde and 7-15% methanol 1t;Trn„Ghin Media: . Water spray, foam, dry chemical, carbon dioxide. Special Fire Fighting Procedures: Wear self-contained breathing apparatus (SCBA) and complete personal protective equipre t. Mmsual Fire"and Explosion Hazards: Nome. Avoid water streams (vs. spray) which may splash and spread flaming liquid. V. R&)C!rIVITY MM: Stability: Stable`: Ba -dou Polymerization: Will not occur Canditicns to Avoid: Exposure:to cold may cause cloudiness and precipitation of polymers which will slowly re-dissolve upon gentle.heating. Inoo¢patibility (aaterials .to.avoid): Avoid contact.with strong alkalies, strong mineral acids. Hazardws Deoaupositi,cn Products: May folim formaldehyde'gas carbon dioxide, carbon monoxide, various hydrocarbons. MATERIAL SAFEPY DATA SHEL1' Page 21 of 2 MM:.PERMAF IX VI.. H[kM HUM DATA: Primary routes of entry. UMMMION, SKIN. 10 Hazard Trntifitat ion: . 1 IIATATICN: Highly irritating,to upper respiratory tract. May cause inflamration to lining of nose, throat, and,lungs, with broncnopne i6nia and edam possible fran extremely irritating exposure. SKIN: Contact with,liquid causes drying, cracking, and scaling. Prolaiged and repeated contact causes a hardening or tanning effect. May cause contact allergic dermatitis. EYE CCNIXT: Exposure to high vapor concentration or contact with liquid causes tearing and severe irritaticn. Contact with liquid causes severe burns. Ili: Poisonous if swallawed.� Causes severe irritation-to mouth, throat, and stomach. Severe stomach pains will follow with possible loss of consciousness. Blindness or death may occur. Flm,4ery and First Aid Procedures: IIMIATICN: Remove patient from contaminated area. If breathing has stopped, give artificial respiration followed by oxygen,.if needed. Keep warm and quiet. Call a physician. SKIN: Remove contaminated clothing. Wash skin well with large amounts of water. If irritation persists, contact a physician. 7 EYE CQMM Flush eyes with water for at least 15 minutes. Contact a physician immediately. INCES`TKU: If the person is conscious: induce vomiting immediately by giving 2 glasses of water and pressing finger down throat, 'repeat until vomit is clear,, then give milk. Contact a physician imrediately. VII. SAFE HMXJM AND USE: Spill Procedures: Eliminate ignition sources, neutralize with dilute solutions of amncxnia or sodium sulfite. Soak up with noncanbustible absorbent material, remove and allow to dry in a well ventilated area. Flush cleaned area with water: Waste Disposal: Imprcper disposal can cause damage to the enviraurnnt. Dispose of dried material in acoordance with federal, state, and local regulations. VM. SPEML PFOMMM INFOMMM: Respiratory Protection: Use NICSH/MSHA approved equipment. A,full face shield/goggles combination or appropriate respirator should be used if exposure limits are exceeded. See Table 1, 29 CFR 1910.1048g. Protective Gloves: Rubber, neoprene, nitrile, or other waterproof gloves. Eye Protection: Safety goggles for normal use. Vent-iIatic : Natural or mechanical local exhaust as needed to stay below exposure limits. IX. S MII PM2MTCNSS: Handling and Storage: Avoid contact with eyes, skin, clothing. .Avoid prolonged breathing of vapor. Do not store for long periods of time below 35°F or above 110OF. ' Keep containers tightly closed when not in use. Wash thoroughly after handling. This information is furnished without warranty, representatiai, or license of any kind, ,except that it is accurate to the best.of The Dodge Canpany, Inc.Is knowledge or obtained fran sources believed by The Dodge Company to be accurate. The Dodge Carpany does not assume any responsibilities for use or reliance upon same. Custoners are encouraged to conduct their own tests. Before using any product, read the label. MATERUL SNFM DATA SLIEST Page 1 of 2 Revised: 04/20/93 I. Pi43= Trade Name.....................: P E R M A G L O Class..........................: Arterial Embalming Chemical, Mixture DOT/t]N Hazard Classi f i cat m...: Fonr aldehyde Solution UN 2209 Matnifactuners The Dodge Campany, Inc. Hazard Rating: FIRE......... 2 4 = Extreme 165 Cambridge Park Dr. HFAi.'i8....... 3 3 = High P. 0. Box 193 RENMaVI!IY .. 0 2 = Moderate Cambridge, MA 02140 SPOMM...... 0 1 = Slight (617) 661-0500 0 = No Hazard II. HAZARDOUS INGMIEM: Common Name Chemical Family CASE Wt% RTosure Limit Fbrnmaldehyde Aldehyde 50-00-0 23 0.75 ppm (OSHA TWA) 2 ppm (OSHA SM) Potential Cancer Hazard (NIP, IAX, OSHA) Methanol or Alcehol 67-56-1 8 200 ppm (OSHA TWA) Methyl Alcohol , (ACGIH TLV & TWA) (At.IH includes skin) Hexylene Glycol Glycol 107.41-5 2 25 ppm (AOGIH NA) (No Federal TLV est.) 1 III.IUMCAL DATA: Bailing Paint (*F)......: 204-214 Specific Gravity (H2O=1)........: 1.055-1.065 Vapor Pressure (mm.Hg)..: Unknown Percent Volatile (by whore)....: 99 Vapor Density (Air-1)...: Greater than 1 Evaporation Rate (Bu Acetate=l).: Partial Greater that Solubility in Water.....: Complete pH..............................: 7.0-9.0 Appearance and Odor: Clear f luoresoent pink-orange liquid, slightly perfumed, somewhat pungent odor. IV. FIRE AND E)MWSICN HAZARD DATA: . Flammable Limits in Air: 78-73%* Flash Paint: 195°F (ZDC) *For solutions of 37% formaldehyde and 7-15% methanol. Exti_*rn�,Sl,ir�Media: Water spray, foam, dry chemical, carbon dioxide. Special Fire Fighting Procedures: Wear self-erntained breathing apparatus (SCBA) and catplete personal protective equipment. Unusual Fire and Etnplasion Hazards: Note. Avoid water streams (vs. spray) which may splash and spread flaming liquid. V. REACTlVITY DATA: Stability: Stable Hazardous Polymerizati : Will not occur Conditions to Avoid: Exposure to cold may cause cloudiness and precipitation of polymers which will slowly re-dissolve upon gentle heatinxg. - In>ooB�tatibi I ity (materials to avoid): Avoid contact with strong alkalies, strong mineral acids. Hazardous Products: May form formaldehyde gas, carbon dioxide, carbon monoxide, various hydrocarbons. MA MIALI SAFETY DATA'SHEET Page 2 of 2 Nme: PERMAGLO VI. HEUM HAZARD DATA: Primary routes of entry .. I[ =ION, SKIN. Hazard Identification: Il ATATIM: Highly irritating to upper respiratory tract. May cause inflammation to lining of nose, throat, and lungs, with bronchopne v ni . and edema possible fran extremely irritating exposure. SKIN: Contact with liquid causes drying, cracking, and scaling. Prolanged°and repeated contact causes a hardening or tanning,effect. May cause contact allergic,dermatitis. EYE CmTwr: Exposure to high vapor'canc entraticns or contact liquid with l d causes tearing'and severe 1.irritaticn. .contact with liquid causes severe burns. immmog: Poisonous if swallowed. . Causes severe irritation to mouth, threat, and stanach. Severe stomach pains wi.11'follow with possible'loss of consciousness.' Blindness or`death-may'occur. Dnergen y and First Aid Procures: Imum d: Remove patient fran cm. taminated area. If breathing has stopped, give artificial respiration followed by oxygen, if needed. Keep warm and quiet. Call a physician. sm: Renove contaminated clothing. wash skin well with large amounts of water. If irritation persists, contact a physician. EYE Comm Flush eyes with water for at least 15 minutes. Contact a physician imTediately. IlJ gram: If the person is conscious: induce vomiting imTediately by giving 2 glasses of water and pressing finger dawn throat, repeat until vomit is clear, then give milk. Contact a physician " immediately. M. SAFE HANCEM AM USE: ill Procedures: Eliminate ignition sources, neutralize with dilute solutions of aimrnia or sodium sulfite. Soak up with noncombustible absorbent material, remove and allow to dry in a well ventilated area. Flush cleaned area with water. 4b^te Dial.: LTproper disposal can cause damage to the enviranment. Dispose of dried material in accordance with federal, state, and local regulations. VIII. SPECIAL PROMM N II is Respiratory Prctscticn: Use NIOSH/M.SHP, approved equiprrnnt. A full face shield/goggles com�taination or appropriate respirator should be used if exposure limits are exceeded. See Table 1, 29'CFR. 1910.1048g. Protective Gloves: Rubber, neoprene, nitrile, or other waterproof gloves. Eye Protection: Safety goggles for normal use. Ventilatim: Natural or mechanical local exhaust as needed to keep TLV within limits. IX. SPE,L PRDOUi'IOISS: Handling and Storage: Avoid contact with eyes', skin, clothing: Avoid pro1mged breathing of vapor. Do not store for long periods of time below 35°F or above 110°F. .Keep containers tightly closed when not in use. wash thoroughly after handling. This information is furnished without warranty, representation; or license of any kind, except that it is accurate to the best of The Dodge Campany,.Inc.Is knowledge or obtained fran sources believed by The Dodge Ccnpany to be aecurate. :''The Dodge Ccgany`does not assume any responsibilities for use or reliance upon same. Customers.are encouraged to conduct theirhdwn tests. Before using any product, read the label. The Dodge Chemical Company HAZARD RATING: Fire 165 Cambridge Park Drive 4 - EXTREME 2 Reactivity Post Office Box 193 3 - HIGH 2 0 Cambridge, MA 02140-0193 2 - MODERK(E 617.661-0500 Health 0 t - SLIGHT special 0 - NO HAZARD MATERIAL SAFETY DATA SHEET a �a I. PRODUCT IDENTIFICATION: //045 Class: Arterial Embalming Chemical, Mixture. Trade Name: PLASDOPAKE DOT Hazard classification: Formaldehyde Solution - UN 2209 - Class 9 ll. HAZARDOUS INGREDIENTS: Chemical Identity, Common Name(s) CAS No. Wt. % Exposure Limits ALDEHYDE: Methylene Glycol 50-00-0 18.0 0.75 ppm (OSHA TWA) Formaldehyde 2 ppm (OSHA STEL) Methylene Oxide Potential cancer Carbinol Hazard (NTP, IARC, ' OSHA) ALCOHOL: Methanol 67-56-1 6.0 200 ppm (OSHA TWA) Carbinol (ACGIH TLV & TWA) Wood Alcohol (ACGIH includes ski III. PHYSICAL DATA: Boiling Point (OF.) 204-214 Specific Gravity (H2O=1) 1.05-1.C6 Vapor Pressure (mm Hg) unkn Percent Volatile (by volume) 79 Vapor Density (Air=1) >1 Evaporation Rate (Bu Acetate=1) Partial > 1 Solubility in Water I romplete I pH 7.5-8.5 _ Appearance and Odor: .;Orange-pink opaque liquid;, slightly perfumed, pungent ,odor IV. FIRE AND EXPLOSION HAZARD DATA: Flammable Limits in Air: 7% - 73% Flash Point: 000F. (TOC) Extinguishing Media: Water Spray, Foam, Dry Chemical, Carbon Dioxide. Special Fire Fighting Procedures: Wear self-contained breathing apparatus (SCBA) and conplete personal protective equipment. Unusual Fire and Explosion'Hazards: None. Avoid water streams (vs. spray) which may splash and spread flaming liquid. V. REACTIVITY DATA:,(.. Stability: Unstable° Conditions to Avoid: Exposure to• cold•may cause precipitation of the polymers, Stable X K. which will redissolve slowly i Incompatibility: `;Avoid contact with strong on heating. (materials to avoid) dies, s"tronc",`mineral- acids. y Hazardous Decomposition Products: May form foimldehyde gas, carbon dioxide, carbon Hazardous Polymerization, May occur `,.monoxide, various hydro ar lons. x ,a Will not occur Y Primary routes' entry': Inha.lati.on,' Skin VI. HEALTH HAZARD DATA: y y HAZARD IDENTIFICATION: EMERGENCY and FIRST AID PROCEDURES: .a 1. INHALATION;: Highly irritating` 1. INHALATION: Remove patient from to ,upper respiratory tract. May contaminated area.: If breathing has cause inflamnation,to lining of stopped, �give artificial respiration nose, throat, and lungs, ,with followed by oxygen, if .needed. Keep bronchopneumonia and ede►na pos- warns and quiet. ,Call a physician. sible from extremely irritating exposure. 2 . SKIN: Contact with liquid causes 2., SKIN: Remove contaminated clothing. drying, cracking,. and scaling. Pro- Wash skin well with large anounts longed and repeated contact. causes of water.. If irritation persists, a hardening or tanning effect. May, contacts a physician. cause contact allergic dernlatitis. 3. EYE' CONTACT: 'Exposure to high 3• `EYE ,CONTACT: Flush eyes with water vapor concentrations or' contac,t� for,at least 15 nunutes. Contact a with liquid causes tearing .and physician immediately. severe irritation. Contact with liquid causes severe burns. . 4 . INGESTION: Poisonous if swallowed 4 . INGESTION: Induce vomiting immedi- Causes severe irritation to mouth, ately by giving 2 glasses of water throat, and stomach. Severe and pressing finger down the throat, stomach pains will follow with applying this technique only if the possible loss of consciousness, person is conscious. Contact a Blindness or death may occur. physician immediately. VII. SAFE- HANDLING and USE: Spill Procedures: Eliminate ignition sources, neutralize with diluted solutions of ammonia or sodium sulfite. Soak up with noncombustible absorbent material, remove and allow to dry in a well venti- lated area. Flush wiped area with water. Waste Disposal: Dispose of dried material in accordance with Federal, State, and local regulations. VIII. SPECIAL PROTECTION INFORMATION' Respiratory Protection: Use NIOSH/MSHA approved equipment. A full face shield/goggles combination or appropriate respirator should be used if exposure limits are exceeded. See Table I, 29 CFR 1919.1048g. Protective Gloves: Rubber, Neoprene, Nitrile, or other waterproof gloves. Eye Protection: Safety goggles for normal use. Ventilation: Natural or mechanical local exhaust, if necessary. Keep TLV within limits. IX. SPECIAL PRECAUTIONS: Handling and Storing: Avoid contact with eyes, skin, clothing. Avoid prolonged breathing of vapor. Do not store for. long ,periods of time below 350F; or above 1100F. Keep containers tightly closed when not in use. Wash thoroughly after handling. This information is furnished without warranty, representation,.or license of fny kind, except that it is accurate to the best of The Dodge Chemical Company's knowle,dgo or obtained from sources believed by The Dodge Chemical .Company'to be accurato.`TTho Dodgo Chemical Company does.nor�assume any responsibilities.for:use or roliance.upon samu. Customers are encouragedIto.conduct`their�own tests :Etelore using any product, road the label. 3 . 'Revision Oate. June 1992 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER that he On-site Swage Disposal System Constructed Repaired( )Upgraded( ) Abandoned( )by O� at ` as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No --67�?4 datedy— 2.Z> Installer Designer The issuance of this permit shall not be construed as a guarantee that the will functi as ' e Date �' d �'� Inspect +'yNo. c 'M Fee � g THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[pplication for Migozaf *pgtem Construction Permit Application for a Permit to Construct(►'u)Repair( )Upgrade( )Abandon( ) O Complete System L/Individual Components Location Address or Lot No. �� �JD�.J�/� Owner's Name,Address and Tel.No. J Asses ap/Parcel / �T 1 _ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �0l7��7�`/ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 'O hhyMo. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank f -eO ,t Z® Type of S.A.S. 101 lok Description of Soil weleg/ - Nature of Repairs or Alterations(Answer when applicable) -��l5fo �� �P �h MOW e 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 Certifi- cate of Compliance has been issued his B d oUiealth / Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. LS Date Issued s! r ,., i+■ Fee JCL v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: f.-. ,PUBCI;C HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS es l "t Z(pprication for 3i.5pogar *pgtem Conotruction Verurit Application for a Permit to Construct(V )Repair( )Upgrade( )Abandon( ) ❑Complete System Vindividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Aoe Ma /Pg 1p�s 0�� • T r N Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other r Type of Building AaAl,h"® /V*eNo. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons._ Plan Date Number of sheets Revision Date Title Size of Septic Tank / DO !ice Type of S.A.S. Description of Soil G✓4J�L°/�7`/9!> 7`�aw e Nature of Repairs or Alterations(Answer when applicable) -Xe3tell 7`f�� MYXI Q/' 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 Certifi- cate of Compliance has been issued t is B do Hea Signed Date Application Approved by % Date ;:Z6 " 474 Application Disapproved for the following reasons Permit No. LS Date IssuedA —————————————————————----——=——---———————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CE TIFY, that the On-site ewage Disposal System Constructed(✓ )Repaired ( )Upgraded( ) Abandoned( )by O! zz D at 54 m n / /0`0 d/!S -*?// as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N dated 1:4- 'l Installer Designer The issuance of this permit shall not be construed as a guarantee that the will functi as srgn Date �3� Inspect THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Wi5po5ar pgtem Con5tructton Vermit Permission is he granted to Construc ( / )Repair( Up ade( )Abandon( ) System located at 3 �< ��'�`^ y and as described in the above Application for Disposal System Construction Permit. The applicant recognizes 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 thi ermit. Date: '" �jo' 1 Approved nr r i ke zo 19 000 3-7 /�ef�idinv wQ r LZ CA'"T ION S E W A G E PERMIT NO. M,6vl�ls-i n VILLAGE ll ,-D - f-�OuaC INSTA LLER'S NAME R ADDRESS B UICDE R :, OR OWNER DATE PERMIT SSUED DATE C0MIPLIANCE ISSUED -s _ .. '' ��� .., / �. I � � . . �.. .. .. ;� .. I 1 /. TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM Mail To: NAME OF BUSINESS: L� �1 ��� -P� � �- `� Board of Health MAILING ADDRESS: -7 Town of Barnstable TELEPHONE NUMBER: .4/-;,, g - P.O. Box 534 CONTACT PERSON: a�Al 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 totalling, 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 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 TOWN OF BARNSTABLE OMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops unsatisfactory- 4.Manufacturers ' COMPANY fah Lj4t�-, �, y'D (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS 3 7:7 S0 0A sno r� Q Class: 7•Miscellaneous M 5`0" QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS` Case lots Drums Above Tanks Underground IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil(C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: . �J DISPOSAL/RECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply &M- 1—, 4, t O Town,Sewer 'Public Won-site OPrivate 3. Indoor Floor Drains YES—L/ NO O Holding tank:MDC Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO ORDERS: Q Holding tank:MDC Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product YES NO 1. 2. WEn (sl41,teie ed Inspector Da e Lf�Lc,'Zel- ICE Zoo t9 i fz 2 r . -711 -b r Lb& Ciowma r