HomeMy WebLinkAbout0135 ROUTE 149 - Health _ �A= _
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Date: 6 -L
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: Aer sA' jS ' SCUD 10
BUSINESS LOCATION: l'43 Cs-rU l_r P-D - /-(4 S-%owzS M 1 it
MAILINGADDRESS: 143 C®Tu fT ED . LA8S-12e.51 Nil-1-5 , HA Mail To:
TELEPHONE NUMBER:(Sad Azg - 1 t Z47 Board of Health
Town of Barnstable
CONTACT PERSON: /`'�4yQ cAr�✓ P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER: C'99 Z.g -71-2q Hyannis, MA 02601
TYPEOFBUSINESS: Az-r S-W-DtQ # S60yyL
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own
use? YES ✓ NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site otherthan your mailing
address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
Antifreeze(for gasoline or coolant systems) Drain cleaners
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
Car waxes and polishes Leather dyes
Asphalt & roofing tar Fertilizers
✓ Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
r/ Paint brush cleaners (including chloroform, formaldehyde,
Floor& furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids PA4t-.�r r'H�►� E�V_
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
I
,lit
Date: 6 D Z
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: /��z"�SA►�SS S�'t�� LO
BUSINESS LOCATION: /-43 C6-rVt-C > b - D Z64&
MAILINGADDRESS: f'43 Co-ry BT U • /t'�A ST�a.S� fit/J.S � � Mail To:
TELEPHONE NUMBER:
Board of Health
���� �'Zg � -7f Z� Town of Barnstable
CONTACT PERSQN =.,/`' y2 �J P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER; (�SZ►$1 Z$ ��129 Hyannis, MA 02601
TYPE OF BUSINESS: A 4 SCE L
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own
i
use? YES ✓ NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your mailing
address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The.Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
I� Antifreeze(for gasoline or coolant systems) Drain cleaners
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
{ Motor oils Pesticides
V
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED .
Degreasers for engines and metal Printing ink'
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
'( Car wash detergents Jewelry cleaners
Car waxes and polishes Leather dyes
I
Asphalt & roofing tar Fertilizers
Paints,,varnishes,stains;dyes PCBs- -
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint&t varnish removers, deglossers An other roducts with "
✓ Paint blush cleaners Y p poison" labels
t' (including chloroform, formaldehyde,
Floor& furniture strippers
hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including`bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids PAi 1'f I IrJ►J
(dry cleaners) ,
Other cleaning solvents
r
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
= x TOWN OF BARNSTABLE
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS h s
�9-d�
ASSESSORS MAP NO. o PARCEL NO.
o —
ADDRESS; / �' RT_ l �j �C'ol(u I j VILLAGE �77Jo✓C AV LLI
14AME;._.. � ILLQA'f.-E=.._.. ..��aAA �
CONTACT PERSON�O/y►i C� s� ��/{,F/��/ PHONE NUMBER' 4l"j,rN
LOCATION OF TANKS: , CAPACITY: TYPE OF' FUEL AGE: TYP : LEAK
Q OR CHEMICAL: _ DEST C T ION
av7v_ cal ate- D r �c%l„GI C— (o 0(9 co n U Q
q
23_A Ao% r,&t)r p ��. WASH nip,
DATE OF PURCHASE OF EACH: 1. 2. 3. 4. 5.
DATE OF FIRE DEPARTMENT PERMIT: ? `
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
PLEASE PROVIDE A SKETCH SHOWING THE LOCATION 'OF TANKS ON THE BACK OF THIS CARD.
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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
,�' Mail To:
NAME OF BUSINESS: AlS�� Q" Board of Health
MAILING ADDRESS: �8.�� � Town of Barnstable
TELEPHONE NUMBER:� �'� 9efz P.O. Box 534
CONTACT PERSON:
Hyannis, MA 02601
�'i�y� � <5
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in q��ptities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES YY�� 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, Refrigerants
Diesel fuel,.%eresenq A2-keati-� 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
y. t � . ....r.,^.ry 3 .+.sir. �.� .... ,,.-.,�`�,_w! g. �„s.,.,rx-..,.ii ;F • ....:.r �.;n .;y ..i.T n �� �,�ti-..v�ti-�....y.�sa-'•-+''� :3"m""Z, #'' nr tr .. � ....,. .-.y n.• "="�' '?' "�'.�"''.t
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory
BOARD OF HEALTH 2.Printers3.Auto Body Shops
O unsatisfactory- 4.Manufacturers
,�COMPANY 111- .Ifs �. aAr '4',.' (see"Orders") 5.Retail Stores
� 6.Fuel Suppliers
ADDRESS ' 3"'/"� 1#4"U Class: 7.Miscellaneous
QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS Case lots Drums Above Tanks Underground Tanks
(, �a IN OUTI IN OUT IN OUT #&gallons Age Test
1Fuels:
Gasoline ,Jet FueNA) zp-
Diesel, Kerosene;#2=(B)
Heavy Oils: /
waste motor oil (C)
new motor oil (C) ,e'f�► h'
transmission/hydraulic f '
Synthetic Organics:
degreasers
e
�PAI
Pi �
Miscellaneous:
C '--1
V1
DISPOSAIJRECLAMATION REMARKS:
1. Sanitary Sewage 2.Water Supply /1,-, st.
O Town Sewer FpPublic if
O On-site, OPrivate
3. Indoor Floor Drains YES NO kl
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
A. Outdoor Surface drains:YES NO ORDERS:
O Holding tank:MDC
EO Catch basin/Dryrwel'1
O On-site system
5.Waste Transporter
Name of Hauler Destination Waste Product
YES NO
2.
t
`� f Person (s) Interviewed Inspectorf ,�' Date
OWN OF BARNS ' " COMPLIANCE: CLAS, c, l: Marine,Gas Stations,REpai.r
O satisfactory 2. Printers
BOA OF HEALT 3. . Auto Body Shops
� '7 n atisfactary- 4. Manufacturers
Ilk: , Q �� �� S. Retail Stores
I�OMPANY � ' (see Orders )
6. Fuel Suppliers
ADDRESS IN 1 I NN x3 Class: 7. Miscellaneous
QUANTITIES AND STORAGE (IN=indocrs; OUT=outdoors)
�1A,)OR MATERIALS Case lots Drums AboveTanks Undetground Tanks
IN 100UT IN IOUTzI Ions erest?
`V
Fuels:
Gasoline, Jet Fuel,(A)
Diesel, Kerosene, 82 `(B)
Heavy Oils:
waste motor oil "(C) .�' JI)
new motor soil. .
transmission/hydraulic
4 .
k �
Synthetic Organics: ti s
degreasers
Miscellanezb
ous:
1
DISPOSAL RECLAMATION REW.RKS: '" l, N., j ``' 777
"Lci,`
1. Sanitary Sewage 2. Water Supply
0 Town Sewer O Public "
�.
OOn-site O Private
�1 ndo o Floor Drains: YES N0� ,M kF'
Q Holding tank: MDC —
O Catch basin/Dry well —
On-site system
4. Outdoor Surface drains:YES NO
0 Holdink• tank: MDC
O Catch basin/Dry well + _-
On-site system
S. Waste Transporter, r Licensed?
r n ctinatien v c ^ 4�
A
t i..
;M,.0 - I� V)
u 81 Person t.e nrviewe Inspector Date
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS: Board of Health
MAILING ADDRESS: �� ZZ—OrW � txG°d�` Town of Barnstable
TELEPHONE NUMBER: P.O. Box 534
CONTACT PERSON: �� G/5le Hyannis, MA 02601
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalli , 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
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 Jl 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)
t� Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy-Health Department/ Canary Copy-Business
TOWN OF BARNSTABLEKnun
OMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
nters
BOARD OF HEALTH satisfactory 3.2.Auto Body Shops
satisfactory- 4.Manufacturers
COMPANY �ogl'y'o/. d zip�� (see"Orders") 5.Retail Stores
6.Fuel Suppliers
f ADDRESS /t? �o�J" v'/. 'l��.r� lass: 7.Miscellaneous
A"'A"'_4UANTITIES AND STORAGE (IN= indoors;OUT=outdoors)
MAJOR MATERIALS Case lots1Underground Tanks
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline,Jet Fuel (A)
Diesel, Kerosene, #2 (B)
Heavy Oils: h�
waste
new motor oil(C)
transmission/hydraulic
Synthetic Organics:
degreasers
Q / `
scellaneous:
a .s
raw
DISPOSAIJRE;LAMATION REMARKS:
rr ,
1. Sanitary Sewage 2.Water Supply ! 1 ; a— v .
O Town Sewer ublic
*On-site // OPrivate
3. Indoor Floor Drains YES_LNO
O Holding tank: MDC
O Catch basin/Dry well • ,�
On-site system , s
4. Outdoor Surface drains:YES lox I
6z ORDERS:
—
Q Holding tank: MDC
O Catch basin/Dry well
O On-site system
5. Waste Transporter
Name of Hauler Destination Waste Product
f YE$ NO
1. " tg;f
2.
r
-7
Person (s) nterviewed Inspector Date
roV Y NF_1VR V�7 1"7 -`�`Ctf1�]i'L7lhit ' GC?i3 ':�2�-Fiat it�e cia3 3lnt'lu��y
1 i ? f,a.. 2.,`Printers
BOARD OF H EAET H satisfactory.* 3. Auto Body Shops
0unsatisfactory- 4. Manufacturers
CC1r4PANY '` I /,s (see"Or' ers") S. Retail Stores
6. Fuel Suppliers
ADDRESS � � Class 7. Miscellaneous
QUANTITIES, AND STORAGE (IN=indocrs; OUT=outdoor
MAJOR MATERIALS Case logs Drums AboveTankis Undetground Tanks'
'I 0 Ur •IN 0 • IN, IOUT N &-g2llons Age
Test
Fuels:
Gasoline, Jet Fuel (A)
Diesel Kerosene, #2 (B)
Heavy Oils.`-"
waste motor oil (C) �--
new motor oil ,�(�) 1 iF
..ice
transmission/hydraulic
Synthetic Organics:
i degreasers_ c,.^
-I V .
Misce• lan us: `f
171 TI
AA
DISPOSAL/R. CLAMATION " SM
REM ►RKS:
. 1. Sanitary Sewage 2y-Water, Supply r
OTown Sewer Public `
P
ion-site rivate f /
3.. I'ndoor Floor Drains: YES NO4,�._
O Holding tank: MDC f +—
O Catch basin/Dry well ' _ 'I,e-,
On-site system
4. Outdoor Surface drains:YES NO �,r✓
O Holding,tank: MDC q ��``
j
O Catch basin/Dry well d_1 �� -dA,,•��'W�!
O On-site system
S. Waste Transporter Licensed?
Name of Hauler ± e` �`.. � a-,Pr Uct YES NO
°�:.P-�
eir: erson s) Int.ervieweaiec U to
.i vvV.IV—vI LJn V1i %-Y I r'A L-JL
O satisfactory 2• Printers
BOARD OF - H-EALTH 3. Auto BodyShops i
unsatisfactory- 4. Manufactrersp1
gam, „ „ S. Retail Stores
COMPANY '`� 1 `J " =�� (see Orders ) ter 21►
_,- 6. Fuel Suppliers G
44 oo 7. Miscellaneous
cr
ADDR9SS F . ' Class:
• '0 �'" QUANTITIES AND STORAGE (IN=indoors; OUT=outdoor:
Case lots Drums AbOveTanks Undetgro.uad Tanks
MAJOR MATERIALS IN OUT IIN IOUT [ IN OUT # zallons Age Test
Fuels: VkV.ip"xi
Gasoline, Jet Fuel (A)
Di.esel(, Kerosene, #2 B)
Heavy Oils:
waste motor oil (C)
.new motor oil (C) 7ET V",
•
transmission/hydraulic
Synthetic Organics: ;
degreasers
Miscel aneous:
DISPOSAL RECLAMATION
1. Sanitary Sewage 2. Water Supply
0 Town Sewer O Public � ,n -l;J +tea +
6 On-site 0 Private
3. Indoor Floor Drains: YES NO ''
Q Holding tank: MDC
'
O Catch basin/Dry well � �,� v ���� r�� _ _,� _ _ n _ _ —
(''� On-site system
4. Outdoor Surface drains—YES—NO
. Q Holding, tank: MDC �:av'c:-� .�:ti. �-•�;�,�� ��..���c,b� �.,c �:�-� ���
0 Catch basin/Dry well
OOn-site system
S. Waste Transporter a tn � s;s ; �' ( ,� >�.� Licensed?
P C t
Name of Hauler_ !.- ti nati on " �' �- '
2• S
:t u e s�n )"°� taca�eaved - K Insp{ecto'-�y Date
f 1 V Y Y IV V :E CUP 1E'CT}L1iG .I GCft��'-`i ,Fldtt��a��fas 6Le�tui
r Q satisfactory; , 2• 1Printers
BOARD OF HEAL H �� 3, Auto eoay Shops
0unsatisfactory- 4. Manufacturers
COMPANY i' s (see"0 ers") S. Retail Stores
6. Fuel Suppliers
ADDRESS Class.
y 1 a 7. Miscellaneous
QUANTI TI ES. AND STORAGE (IN=indoors; OUT=outk
MAJOR MA7ERiALS Case lots Drums. AboveTank;s Undetgroued Tanks
IN UT I 0• I p 6 gEllonse
Fuels:
Gasoline, Jet Fuel (A)
Diesel Kerose , #2 (8)
Heavy Oils.—'"_�• "
waste motor oil : (C)
new motor oil ,.•( )
transm/son/hydraulic
Synthetic Orgsnics: { y i
,,degreasers .
.... -
Misce 1dhepus:
i .
i
DISPOSAL RECLAMATION % REW.RKS:
1. Sanitgry Sewage 2. -Water. Supply r
_
Q Town Sewer �. Un
Public
'On-site Q Private - �
3.. h door Floor. Drains: YES N0 �►� - ... �'" `
O Holding tank: MDC�
O Catch basin/Dry well L �'
On site system RVERS' j ir' s
l
4. Outdoor Surface drains:YES NO
Q Holding-tank: MDC
Q Catch basin/Dry well
Q On-site system s
S. Waste Transporter '� T":;
P Licensed?
.,�j,
Name of Hauler_ qtinptjnnAA
- }-�+` r /
M .
u 23`•It.
" erson s) Int.erviewea per D t(�e'