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HomeMy WebLinkAbout1418 RACE LANE - Health 1418 Race Lane,Marstons Mills A= 064 - 024 i I 1 r " 11— TOWN OF BARNSTABLE V LOCP;EI'ION`40�O-zy ?/,-& SEWAGE # VILLAGE �/.l hE0 / �PQ,I� ASSESSOR'S MAP & LOT ((--d -ga-3 *NS P,C7Z*p'SNAME&PHONE SEPTIC TANK CAPACITY ©U .10n� LEACHING FACIL=: (type) /�� (size)' /SOU e!20 NO.OF BEDROOMS BUILDER O OWNER PERMIIDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 6 0-40&-m; ��i �� 1������'� 4(� �(��� ����, o U' a9 ' S�' ' / 3c LO G7T ION SEWAGE PERMIT NO. / �r- AA40W 003 VILLAGE INSTA LLER'S SAME & ADDRESS KgM R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 6 t. =! ., �� iy_ � � //� v J O 1 it y� V i a,, . . ��� t'1.. � ,. � �� � y�, ^� �y � �1 � � i I'I� No.....3.! ...... FRs ............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH � OF..................................... .................................................•. , ppliration for Bhipmal Work.5 Tomtrurtinn lirrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ,/(an Individual Sewage Disposal System at:I NIA . t . � M 06 Y- ...... ....... .... .... . .....- -... . �. . � ------.. ---------... . L do dress or Lot No. ... .. _ ...........%�... -- ----------------------------------- ---------------- ---- ------ ........ - q re W .... ....... ... ............. --.........-- ----....................................... .1� Ida __.._. .,,��.. .. --------- a Installer Address � Type of Building Size Lot_ .....................Sq. feet U Dwelling - No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria a Other 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.--.Rt........... Diameter-------(.......... Depth below inlet...(•o............. 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-_________---•-----_-__. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O c Description of Soil.. .. - -- - --.................................. \ x •-•-•-••---•----•-------•-----------•-•..................• -----------•--•-----------•-----------------•--•------------------------------._.....---••...... ......................... W ••--------•................................. ---- �k'-----�---��� ----------------- e UNature of Repair Alterations— nswer when appl• bl 44 % - Agreement: The undersigned agrees to install the afored"escribed Individual Sewage Disposal System in accordance with the provisions of iITi.;,;. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has �.. ..D issued the oar ,o health. / g Signed-- -•------•--•-•----------I==--•------------------------•--- ..........._ -D _/. Date Application Approved By. ./G---------------•-•-••••-•.... 6 =--- .. r... Date Application Disapproved for the following reasons:................................................................................................................ Date �- �,e.._. stir.- -- SS11 ..�..---.. _.....---•�. ---------- .: ip No....; r /'-•-•-- Fps............._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... ......:..................-.-....OF......................-..-._-..-...._.................................................... Appliration for Disposal Worko Tonstrnrtiun ".motif Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sygem at.... ... /ram ....... ........ ........................•---.......-------- -•----------------------................-" .�t ti dr ss or Lot No. (! r �,�aµ ; Addres —�� ..... ...... .................... .... .................. __._.___--'-- -� Installer Address UType of Build q Size Lot. _..__.___._Sq. feet ,� Dwelling—No. of Bedrooms.ot...................................... Attic ( ) Garbage Grinder ( ) 'k Other—Type T e of Building _______________ No. of ersons._...______.._______._._._._ Showers — Cafeteria a YP g ------------- P ( ) ( ) al Other fixtures _"---"""""-"" _______________________________ WDesign Flow................____________________________gallons per person per day. Total daily flow----........................................gallons. WSeptic Tank—Liquid capacity_........:_.gallons Length................ Width................ Diameter................ Depth................ 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........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit______._____________ Depth to ground water____________________.._. (i Test Pit No. 2................minutes per inch Depth of Test Pit----_............... Depth to ground water________________________ J�................................................................................................................... DDescription of Soil-""""-""-----"--""••--�.__ �" ........___.."---"-"--•--"---"----"---"""""""""----"-"---"-""-""""""-"""""-"""""""""-•----"--""..................•--"" x _ w ; ----- �p4 ----•-___ U Nature of Repair Al erations sw r w nap ' ablM / � ____._____•---------------- .____._.._._.__.. � Agreement: The undersigned agrees to install the afodredescribed Individual Sewage Disposal System in accordance with the provisions of T IT LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be s d b ar iealth. igned _______________________________ ______ ____ ______•___ _ ______- ;" t® 7 Application Approved By....... .----.-•--.---•--"................•-...._____________.-_:_...________------------ Date Application Disapproved for the following reasons:................................-----------------------------------------------------------------------------•- ......_..•________________________________•-_.___------•--------•••-_....--•---_........_•••--------_____.________•-----_____.___-------- ............................................................... Date PermitNo................� ................ Issued-............. ......................................... Date THE COMMONWEALTH OF MASSACHUSETTS ''N BOARD OF, HEALTH �.�•�s����rr ..OF.........- 1i�.f ;...-.... Trrttfiratr of Toutphaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (.,, ) or Repaired O by.............. G F/c .........I............ ....----"............... .."-"--...-.""--._..........."---•-= "---"-"-"-•-........._.._...._ ,y Installer at............... ............................................................• eaG1 A G old#d S�'W�� ---------------•------- x• r t - has been installed in accordance with the provisions of TITIZ I'- of The State Sanitary Code as+described`•-t�o(t he application for Disposal Works Construction Permit �'o _; �'._ / �� y'`'/�s THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...... ........................................tk � ____________________ Inspector ................... ----............................................... .. µme: I,��F���: OLEO �66,��• ..:..i:dwa_. .. �vy�..Y`ta.'a::„: r i_?+:i.-...�. � •tit Y Y � a THE COMMONWEALTH ?F MASSACHUSETTS BOARD OF `H&ALTH ........................... OF................ - t1 .. .: NO............. ..�. FEE.......... �i �a �t1tlan =ran rrntit ,,.M , Permissionis hereby granted.......?C----------------•-• ------------------------------------------•-----------------------------•--•------------------_________-•-•--- to Construct ( ) g}rZ4pZir ( *iLn ,Ind ividualemee/ sp`bsal System 7 atNo_______________•----••-••---."'-----"-"-- ="" -•-- ""- ""-"-""""""""" -- "--------------•- Street r ' as shown on the application for DisposalWorks Construction Perrn>t'N4o_____________________ Dated__. • i, S:vfit Y ., _.._ ____________________________________________________________________ ""? Board of Heal " ��"�!, DATE............................................................... " �.; 1 f r_ . FORM 1255 HOBBS WiWARREN, INC PUBLISHERS_'-- .--yg�• r , / v 00 lb t rod 1 BOR'TOLO'TTI CONSTRUCTION, INC. ka �' , e� 765 MA 02 508-7�B9 R0AD,MAST 08-428-892G OFAX: 5 8 4NS MILLS�28-9399648 � y�lly�FpllgBl199j ,v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO 1� PART A Z - �`� � CERTIFICATION P � roperty Address: d Date of Inspection: Inspector's acne: Ownees Name and Address: Q CERTIFICATION STAT .M .NT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formedlV e on my training and experience in the proper function and maintenance of on-site sewage disposal ems. The System: Passes Conditionally Passes Needs Further Eval ion B e oval Aproving Authority Fails Inspector's Signature: Date: 7 The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: A)SYST PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - :t - 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r CERTIFICATION(continued) . Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four 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 Obstruction is removed 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 the public health, safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE' ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2`_ l_ J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: _Pumping information was requested of the owner,occupant,and Board of Health. ,,--None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. t,"The system does not receive non-sanitary or industrial waste flow. _jZThe site was inspected for signs of breakout. __LGAII system components,excluding the Soil Absorption System, have been located on site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid,, ,depth of sludge,depth of scum. hee size and location of the Soil.Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- M . kfi s iF i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RF.SIDENTLAL: Design Flow: 33t,�' gallons Number of Bedrooms: Number of Current Residents: Garbage G.rinder:�U Laundry Connected 1'0 System:` _ Seasonal Use:aP� Water Meter Readings,if3}'ailable. Last Date of Occupancy: CO MERCLAIJINDUSTR_IAL �C) Type of Establishment: Design.Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 'w r System Pumped as part of inspection_ If yes,volume pum d: —:gallons, Reason for'pumping: TYPE OF SYSTEM: L/ "Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): AP ROXTMATK AGE of all components,date installed(if known)and source of information: .,.; Sewage odors detecQ when arriving at the site: -4 II f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: v Depth below grad Material of Construction: �oncrete metal FRP Other (explain) Dimisions: / Sludge Depth: ' Scum Thickness: ' Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid 1 1 in r lation to utlet invert,structural integrity evi ence of leakage,et .) Q 1060 f� 01 GREASE TRAP: ( Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) — — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK:Ab Depth Below Grade: Material of Construction:—concrete—metal FRP—Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: V/ Depth of liquid level above outlet invert: Comments: (note if 1 1 and distribution is eq al,evide a of solids carryover,evidence of eakage into or ut of box,etc.)_ ,ltd. -464 � ffia a V;t ,-O- � /J,coO l Ir— PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,` SOIL ABSORPTION SYSTEM(SAS):_, (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits, number: Leaching chambers, number: Leaching galleries,number: , Leaching trenches, number, length: Leaching fields, number,dimensions: Overflow cesspool,number: Comments: (note condition of soil,signs of h raulic ailure lev I of ponding,condition of vegetation, i CESSPOOLS: 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions:__.._ Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - x a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (conlimied) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. 6!6v " I 0/I yco &9 o a9 � DEPTH TO GROUNDWATER: Depth to groundwater: / Feet ��II Meth of Determination or ppr mation; 5 �� l,41- ax -7- Q) LOT 3 � �n SHED LOCUS AMP PLA IV REP 9484.E .� co rT PLOT PLAN OF ro ON Of AA ✓ s s}. spy L�SF°�tl.A..l�F Ce4�+�i7 LOCA9'O A7° r. i p�7� AREA�,��t3°rx � . �,,,�� � � MA -, ,r1 is� vp r r q Sri e1����1��'•a.��.i.j S MIA P EPARA.nD FM ql V N 23, 20 e 4.7 RE10' ,. «sa a � Ao SO 0?0. BOX P. . _. UNIT 1, 40 1NDUSMY MAR.971 NS MILLS; Mrs j5o4?-•-.o,?8— a55 F.A. - tI! YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 for years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L._ it does not give you permission to operate.) Business Certificates cates are available Main Street, Hyannis, MA 02601 (Town Hall) at the Town Clerk's Office, 1a`FL., 367 parr �' r DATE: Fill in please: of z fi d ma 's APPLICANT'S YOUR NAME/S: V,' ?� BUSINESS YOUR HOME ADDRESS: LG., •A TELEPHONE # Home Telephone Number S'Ge- E - NAME`OF CORPORATION: - NAME OF.NEW.BUSINESS` 1­xc� '6 -�4icY :. TYPE OF BUSINESS e IS TkS A HOME OCCUPATION?: YES NO ADDRESS.OF BUSINESS '6J ,lr - �tr S MAP/PARCEL NUMBER (Assessing] When starting a new business there are several thin you must do in order t 9s Y o be in compliance with the rules P and regulations of the Town of Barnsts'ble. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. -.(corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. .BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH -This individual h s ormed o e quirements that pertain to this type of business. MUST�YV1!'TH ALL HAZARDOUS L`: "lI-ATION ** MATERIAL" � Authorized gnature COMMENTS: 3. CONSUMER AFFAIRS A RS (LICENSING AUTHORITY) This individual has b n informed of th, licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: r .. Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: ,artc6CS1-200e ��/►�►5 �i�� BUSINESS LOCATION: IV1 44) /3"'a La , /Ll�i-��+-is /_;,Vs INVENTORY MAILING ADDRESS: J"//(r IaC-e L'�`1 ��� � �'I����s TOTAL AMOUNT- TELEPHONE NUMBER: CONTACT PERSON: S-O& yeti S EMERGENCY CONTACT TELEPHONE NUMBER: ��� �^g � MSDS ON SITE? TYPE OF BUSINESS: �1Qrzlsc �2 INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Lastshipment f p o hazardous,waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants j Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible AL Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor&furniture strippers Other products not listed which you feel Metal polishes may,be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) 410/7 Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers 1 t Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS TOWN OF BARNSTABLE ,�y t UNDERGROUND FUEL AND. CHEMICAL STORAGE -YSTEMS lf � ASSESSORS MAP NO. / PARCEL NO. ' ADDRESS: / ! t� / t Ol C e e-y/7 f' VILLAGE NAME;.- CONTACT PERSON PHONE NUMBERZ47 LOCATION OF TANKS: CAPACITY: TYPE OF FUEL. AGE: TYPE: LEAK OR CHEMICALS DETECTION SYSTEM' 16 O14 4 if s�_ ear n e r /2 a 4esC 5760 Q' ��I�YIaK e C' A /_ ��7� _DATE OF PURCHASE OF EACH: 1. �fi. 2. 3. 4. 5. `DATE O`F FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS Donald 0 Patten Rac{ Marston Mls MA 02648 PLEASSHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. _ , O / V a c �'. 'P 40 J CENTERVILLE QSTFRVILLE FIRE.DEPARTMEN170, T "PER IT FOR STORAGE "OF rut OIL F it �^ `. ti s �In accordance with provisions of Chapter 148- G L and Regulations made under authority thereof _ `& xl7on Patton R' Zeulazr Name Name s occupant) ,;�,-,�` • (InStalier) Pva ty,. tpgn + �Address Address.. �: Bumer � � -Storo e � Y fir. e� w"! of :Tank .... Mari aturer ' QQf �g t Moc No o Fy5iz� 0,BMW�Cc a lo►i" �T2iCler :oU2[� Ap y� f `Moss Approval`;No .. 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' HSE.'s" t,� PREPARED FOR: 91. 0 o 2 �sXemeaaa SCO TT & PATRICIA VIENS w7 c�Fo°h�� o JUNE 23, 2006 LOT 2 STEPHEN ► REV- o a � 7 A m REV REV R=1392.46' L=179.99 - :��.T, �e IO r YANKEE LAND SURVEYORS RACE LANE GRAPHIC SCALE & CONSULTANTS 40 0 20 40 e0 P.O. BOX 265 UNIT 1, 40 INDUSTRY ROAD MARSTONS MILLS, MA 02648 TM 508-428-0055 FAX 508-420-5553 1 inch = 40 ft. SHEET 1 OF I JOB #- 54097 JF