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HomeMy WebLinkAbout2929 FALMOUTH ROAD/RTE 28 - Health A2929 Falmouth Rd. M.Mills =/eZ/ —OHO Ts&p"49C SA Garden wee 7 + 1 od APPROVED /I .............................. Sernsuft cones Doperman , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Divi-pu3Ml . orlw Tomitrnrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ()e,) an Individual Sewage Disposal System at: 2 Z Q.S���C�J►� G1a-tL�1 F,�.�s �jrap ................................................................. Location-Address r t No. ........... - N---------------------- ....... . .......................................... --------------------------------- Owner Address Installer Address UType of Building Size Lot---��-d,�__ �®.-..Sq. feet Dwelling— No. of Bedrooms-----------------------------------------___Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- ------------------------------•--•-------•--•---------------. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width,.................... Total Length,.1_-----..___-__-_ 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. I________________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_-:...................... a' •-•-•---•--•.......................•-------•-------•----•---------------•--------------.......----•-.............................. ----- ----------------- --••- 0 Description of Soil........................................................................................................................................................................ x . U -•--•-••-•-•---- ----------••••------•----------•-------•-------------------•--------•-------------•-••-----•------------------------------------...................................................... W -------------------------------------------••- •••--------------------------------------------------- --------._...------.....----••---------------•-•-•-•--. •---- U Nature of Repairs or Alterations—A wer when applicable.--J."�' ._.�--.__lQ12 cS .; ._.. _.r,`ST*--•• 1 .....-- L....-•-•41` .....-/N'i-ICTIL.�i'S� ©..-5" trlcr f t Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The;umdersigned further agrees not to place the system in operation until a Certificate of Compliance,. as een issugidby e,board of health. SignedC----- =------ ------------- .............. ... .. Date ApplicationApproved By ............... .... � �... ............... ..................................................................... ................Date..........-....... Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------ -------- ... ............. ..... ..... ........ ..... . . ...........................................I............... ........................................ D q ate PermitNo. ............f.....4Y.--------- !/------------------- Issued ...................................... -- . . ...... Daze ` t a No. _........_....... 4. Fps.....--•-..®............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF"BARNSTABLE j AVVfiration for Bi-nVo!3ttl Works Towitrurtion Faermit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ........ -------•--•---•-••-•-------------------------•---------••---------•-•---...... -•_-----------•------.....-------------------------------•--•----••-•--••-•----••-- _ Location-Address _ Aj _. /� or t No. --, Owner Address W r`'Q!t i G I o-r) 7 ��� ,�i S;�c.0 �ro � ) rf S t,+i.4 Z-�p`� ,FYI r /7-1 r t I,_S ---------------------•----------------------•---•-•--•-• -•--•------------•-•••-•--••-- ......................................................... ------..............--- Installer Address UType of Building Size Lot._._,z� ..Sq. feet Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons----------_-.._-_.__._.---. Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- ----------------------------------------•-------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width-------------_- Diameter.....--......... Depth................ x Disposal 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........................ (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -----•---••------------------------••------------•------•-------••----------•-•--•------------•.._......--••----------•---••---••-•-••-•-•--•-•--............ xDescription of Soil........................................................................................................................................................................ V ......-•-•-•--•--•-----------------••---•••--•----••-•••-••-•----••-----•--------•-•••------•••------•------•----•-------•------------ -----------•--................................................... W Z. ----------------------------•---------------------------------------------------....----•-----•----------------•-------.....----------------------------------------•--•-••-•---•-•--------•---••------- U Nature of Repairs or Alterations—Answer when applicable�_..I.^J -!r'aa 1-.....'---'.....�t?�.... r.. ..........�t__ I-r ---- 7- _N r f =p .S i Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has •een issu-d by the board of health. Signed L ............ 'LDare Application Approved By ......................`. .�...... ......... Date Application Disapproved for the following reasons: ............................................................:, ........................ --......................... ........ ........................................................................................................ ....... . ........ ................................................ ...... ........................................ Dare PermitNo. t-/ ` l -------------------- Issued ---.....---------......--------------------------------------------- Date --------------------------------------------------- --------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�elr#ifi ate of 0-1-umpiia nce THIS IS TO CERTIFY_,That the Individual Sewage Disposal System constructed ( ) or Repaired (� ) by --------- Incraller _ at ................. - ::. 7 �.. - �` � "1 L l has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -----�y.'._... /.-----------. dated _ -- ----------------- ------- -- - - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... ! I ------- ` .--------------- Inspector ...... ..../f- � ---A-----------­-- - Y ---------------------------------------------------------------- ---------- THE COMMONWEALTH OF MASSACHUSETTS ` 00 G BOARD OF HEALTH i �1 �, TOWN OF BARNSTABLE vo..9`�_ (� FEE........................ UWVviitt1 WorkpTomitrudian Psmit Permission is hereby granted................ !j`` '.. .�L"�......_._...-`-'r'J.`�? �V0;'i to Construct ( ) or Repair ( ) , Individual,Sewage Disposal System -7��-� ZL:/ F- c:._S� chit t atNo. cJ ------•---------•-•---------------------------------•------•----------- Street as shown on the application for Disposal Works Construction Permit No Dated Dated........................................... __ ---- z r?-- - ------ �r - Board of Health DATE---------------I.-` / L FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS i �I i' ! / �. I T►ETow� Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 Y BARMA�BLE.�` 200 Main Street• Hyannis, MA 02601 �PrFDMP+a,O TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT - Business Name: 6010M Date: 03 0(W Location/Mailing Address: DU- Contact Name/Phone: Que'rapb Inventory Total Amount: C (�� MSDS: Q,S License#: lid Tier II : Labeling: Spill Plan: Oil/Water Separator:_NIA Floor Drains: Emergency Numbers: Storage Areas/Tanks: aallon U Srat mAw lam cab tb 2 cme Emergency/Containment Equ nt: Pi Waste Generator ID: NIA Waste Product: Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS 00 C"k0,0 e `n ender Or NOTE: Under the provisions of Ch. 111, Section 31, of the Gen ral 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: 0 v •U Inspector: + Facility Representative: WHITE COPY- HEALTH DEPARTMENT/CANARY COPY- BUSINESS Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 MASS.�e.g 200 Main Street• Hyannis, MA 02601 " ,6p M ,0 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT rE0 A'S Business Name: � Too We W 6 ,64 tx. s- ^nz Date: 0 9 6 R I Location/Mailing Address: 1 Contact Name/Phone: i1 Inventory Total Amount:_ MSDS: License#: Tier II : Labelina: � Spill Plan: Oil/WaterSeparator: d A Floor Drains:�V)h EmergencyNumbers: Storage Areas/Tanks: 0 6 '' .4 tl ' Emergency/Containment Equipment: a T d" �n Waste Generator ID: Waste Product: Date&Amount of Last Shipment/Frequencx: NIALicensed 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 V 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: Inspect l Facility Representative. WHITE COPY- HEALTH DEPARTMENT/CANARY COPY-BUSINESS f m omk TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops O unsatisfactory- 4.Manufacturers COMPANY (see Orders ) 5.Retail Stores 6.Fuel Suppliers ADDRESS Class: -� 7 7.Miscellaneous __W/ 4UANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALSCase lots Drums Ab"Ve a. IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel(A) Diesel, Kerosene,*2-f4W Heavy Oils: waste motor oil (C) new motor oil (C) transmission/hydraulic Synthetic Organics: degreasers E' Miscellaneous: DISPOSALfR.E(7LAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply O Town Sewer ublic c. YOn-site ZPrivate eke 3. Indoor Floor Drains YES—L/NO � O Holding tank:MDC Catch basin/Dry well ,�; 1. x O On-site system 4. Outdoor Surface drains:YES �NO O ER : O Holding tank:MDC Catch basin/Dry well U.0 Sys Was a Transporte���,.�r� ��'� Narne of Hauler �d • it _r YES NO 1. 2. n _"- �w� Person (s) Interviewed Inspector Date k/.k,"d , � � TOWN OF BAR STABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops unsatisfactory- 4.Manufacturers COMPANY r2? �� (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS � Otot, � (;]ggg; 7.Miscellaneous /f/., >'e'es QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS _ IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline Jet Fuel (A) Diesel, Heavy Oi s: waste mo roil (C) new motor of transmis4*0yraulic Synthe c Organ'cs: degr asers Miscellaneous: 42. i r �✓� o , DISPOSAURECLAMATION RE S: 1. Sanitary Sewage 2.Water Supply O Town Sewer Public oP/On-site /rivvate 3. Indoor Floor Drains YES Y NO O Holding tank:MDC_ l O Catch basin/Dry welly% G O On-site system 4. Outdoor Surface drains:YES NO ORDERS: O Holding tank:MDC Catch basin/Dry well O On-site system 5. Waste Transporter Name of Hauler Destination: Waste od 1. X AV YES NO 2. Person (s) Interviewed Inspector Date f TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair BOARD OF HEALTH o Satisfactory 2.3nters .Auto Body Shops unsatisfactory- 4.Manufacturers ' (see"Orders") 5.Retail Stores COMPANY 3 6.Fuel Suppliers ADDRE A4 Class: 7.Miscellaneous p4'�l � QUANTITIES AND STORAGE (IN= indoors;OUT=outdoors) MAJOR MATERIALS Case I ots Drums Underground Tanks IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel(A) 1*7e`sel, erosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil(C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: 1z _Spr0Aj 1j- Zcs -tni►dc+ti.9 zo va-e ,4.Q DISPOSAIJRECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply /tl-(,b 3 3 - O Town Sewer Public ml�t �'On-site O Private �o ,l�i . too ft eG 3.Indoor Floor Drains YES NO r � O Holding tank: MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO ORDERS: O Holding tank:MDC 06'/4 j@ C"ll CA"-1aA;,imu4yt ` O Catch basin/Dry well v r O On-site system 5. Waste Transporter Name of Hauler Destinaltiolf od YES NO 1. 2. ` q 171' er n s) Interviewed V, Inspector ate i TOXIC AND HAZARDOUS MATERIALS REW TRATION FORM NAME OF BUSINESS: MANO► C1 'S G'Al2D,co 6sNTmL Mail To: BUSINESS LOCATION: 7_70 AT Z9 OSTERVIU-E, M4 OZ655- Board of Health MAILING ADDRESS: 55"8 �N E FALMou ff-w� E. F�t.MoUM ,rvp 02 Town of Barnstable S3b p O. Box 534 am TELEPHONE NUMBER: 5i0d• qZO- gL4Lg Hyannis, MA 02601 CONTACT PERSON: WILL4ANI F(TZPa`rp_tc_L EMERGENCY CONTACT TELEPHONE NUMBER: 509 - SH19-'gNL Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in qua (ties 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: .27 Z-7 2`T 4%, DSTF_iLuiu_F_ M4- 0 26S� TELEPHONE: 50f�—y2D-4q2R 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 2,00&ft,Diesel fuel, kerosene, #2 heating oil SO}-60t`Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants 1pa0 ; 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 jQD 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 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM Mai I To: NAME OF BUSINESS: �4Nfl°U�`�.5 �Do Board of Health MAILING ADDRESS: ;622 2�r 2S ®STFR-y« Town of Barnstable TELEPHONE NUMBER: 5ZA—`t4?q — P.O. Box 534 CONTACT PERSON: VA- L - /kAt4-mil-Y 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 when stored in quantities totalling more than 50 gallonsliquid volume or 25 pounds dry weight. 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) G e, Jet fuel Refrigerants ✓ Diesel fueK kerosene, #2 heating itd Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) D -S f'�"s Degreasers for engines and metal Photochemicals (fixers and developeIrs�� <av bs 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 A i i�,�-oarS Paints, varnishes, stains, dyes L/ Fertilizers (if 6t 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) --0j-rP00,e-<; Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business S, ;, TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM Mail To: NAME OF BUSINESS: MA Non)CY S Board of Health MAILING ADDRESS: 222cl 2'1 28 Town of Barnstable TELEPHONE NUMBER: -PqS- q'�L) Z P.O. Box 534 CONTACT PERSON: I�PvL.- 1`AA t-IoAVF-Y 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 when stored in quantities totalling more than 50 gallons liquid volume or 25 pounds dry weight. 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 t fuel Refrigerants Diesel fueukerosene, #2 heating oil ='� Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developersj'S 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 t/ 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) n,sr P oo e =�)C ,L)o 0 t L :- Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business t, TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops O unsatisfactory- 4.Manufacturers COMPANY b� (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS C1aSS' 7.Miscellaneous QUANTITIES AND STORAGE (IN= indoors;OUT=outdoors) MAJOR MATERIALS Case lots 1Undergroundove 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 O Town Sewer �Public '-On-site Private 3. Indoor Floor Drains YES—NO O Holding tank:MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO ORDERS: Q Holding tank:MDC O Catch basin/Dry well O On-site system 5. Waste Transporter Name of Hauler Destination Waste Product YES NO 1. 2. r P ' son (s) irri7erviewed Inspector Date s TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: /d 41g_ s° C Mail To: BUSINESS LOCATION: —e Board of Health MAILING ADDRESS: 1,a Town of Barnstable ,P.O. Box 534 TELEPHONE NUMBER: (-30 2-6 Y4�z Hyannis, MA 02601 CONTACT PERSON: 1?171 72A 7/Zc A EMERGENCY CONTACT TELEPHONE NUMBER: 17/,e- z1'kzlZ. Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quant' ies totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES L,1 NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store: Quantity/Case Quantity/Case Antifreeze (for gasoline or co ant systems Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants/f-t7Z4/,'9 SQL/ ^ c Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants -30 iese , kerosene, #2 heating oil - ®ol Pesticide insectici � / Other petroleum products(. gre , lubricants rodenticides) -5�4 Degr�as�(es fo n�nd 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 alnt varnishes,4ams 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- ther 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 solventsc�-��G� Bug and tar removers Household cleansers, oven cleaners White Copy- Health Department/ Canary Copy-Business r' .6 TOWN OF BARNSTABLE MPLlANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops unsatisfactory- 4.Manufacturers COMPANY ��� (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS 2 9Z 9'�t' 2 Class: 7 1 7.Miscellaneous 04t�_ _ � XA QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS Case lots 1 Underground IN OUT IN OUT IN OUT #&gallons Age Test Fuels:, s ~ Gasoline,Jet Fuel (A) Diesel, K_ern�P� Heavy Oils: waste motor oil (C) new motor oil (C) tvan�aplhydraulic Synthetic Organics: degreasers 0 Miscellaneous: DISPOSAI✓RECLAMATIO REMARKS: �-�, 1. Sanitary Sewage 2. Water Supply 4_xz 4� V IV.- 0 Town Sewer Public , /(;-I/On-site OPrivate 3. Indoor Floor Drains YES I/ NO O Holding tank:MDC ( J �- .V Catch basin/Dry well- :�5 :U -dr Z14 d O On-site"system , 4. Outdoor Surface drains:YES NO : Q Holding tank:MDC 44,1 O Catch basin/Dry well O On-site system 5. Waste Transporter Name of Hauler Destination Waste Product YES NO 1. 2. A <12 e on ( terviewed Inspector fT Date 5 M EAD KEEPING YOU ORGANIZED No. 10230 H163 � y MIN.RECYCLED WRIATNE CONTENT 1096 ce .d pberu�l�s. POST-CONSUMER MR s�oi�vo MADE IN USA GET ORGANIZED AT SMEAD.COM ( 2 --02b -- —= 7� =/5-1 --_— LOCATION : SEWQC;E PERMIT MO. 1?s7�.vo lie_ . Ih1ST&LLER 5 1 &tAF- ADDRESS BUILDER 5 . ►J &ME - ADDRE SS DIaTE PERNA T ISSUED DATE COMPLI W-ACE ISSUED : Vt if /bod �AL h '0