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0159 ROUTE 149 - Health
D'78�D19 �-kIZ�� / 5 M EAD KEEPING YOU ORGANIZED No. 10230 H163 sustaraasv: MIN.RECYCLED rtU►TNE CONTENT 10% CedFRW=,-,c POST-CONSUMER mine pmn WAMO MADE IN USA GET ORGANIZED AT SMEAD.COM �2 pfW re, Town of Barnstable SCO Office:508-862 644 Public Health Division Fax:508-790-6304 BARMARS L 200 Main Street• Hyannis, MA 02601 ,b M A,O� TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT rF0 MAC Business Name: 4"li Date: y Location/Mailing Addres : Q ^ P+'tia S ► U Contact Name/Phone: -iru L(A hW-_4 Inventory Total Amount: MSDS: �Pc' e� License#: A0 C Tier II : Labeling: Spill Plan: ACS Oil/WaterSeparator: Floor Drains: Emergency Numbers: q', Storage Areas/Tanks: V* l ty,50 n i' Emergency/Containment Equipment? [Date aste Generator ID: tub, b Waste Product: �y &Amount of Last Shipment/Frequenc- censed Waste Hauler&Destination: i f1C L��Ih r,her 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 draulic fluid (including brake fluid) Windshield wash otor 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 J 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: labdVaSL& `n5 6 '`sl Inspector: , Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS 7 dr?g - O2o Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-79.0-6304 • BARNSTABLE. • 200 Main Street• Hyannis, MA 02601 059. prFOMP TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: Dat Location/Mailing Address: L Contact Name/Phone: 67 dv ii pp Inventory Total Amount: A MSDS: Ctl License#: Tier II : Labeling: Ues Spill Plan: a Oil/WaterSeparator: A ` Floor Drains: No Emergency Numbers: Storage AreaslTanks: Emergency/Containment Equipment: a Waste Generator ID: Waste Product: Date&Amount of Last Shipment/Frequency: Iv Licensed Waste Hauler&Destination: �V 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 Y 9 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 e/ 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: 'lJ & bcnot., ai Inspector:o Facility Representative: Cl WHITE COPY- HEALTH DEPARTMENT/CANARY COPY- BUSINESS TOWN OF BARNSTABLE Date:0/ /2 0 / Zoit TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY q NAME OF BUSINESS: -4 �C�wv BUSINESS LOCATION: 13'5 1)46( tAa, s r,g ��IDS �,�'J�, , INVENTORY MAILING ADDRESS: _ fox 63H 00 TOTAL AMOUNT: TELEPHONE NUMBER �y— CONTACT PERSON: � ®sue_ EMERGENCY CONTACT TELEPHONE NUMBER: �'1--5 6 — 1'-1,S�`4 MSDS ON SITE? TYPE OF BUSINESS: 1-CtiIAAs LC.t IDS INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of 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 material 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 I Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants 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 Miscellaneous 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 Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Ap cant's Sig re Staff's Initials Number Fee 206 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that Village Garage Inc. .-------------------------------------------------------------------------------------------------------------------------------- 135 Route 149, Marstons Mills, MA .----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- Restrictions: .................................................................................•-----.....---....------.........------......--------.....---------........-------. This license is granted in conformity with the Statutes and ordinances relating there to, and expires 06/30/2021 unless sooner suspended or revoked. ---------------------------------------- JOHN NORMAN DONALD A.GUADAGNOLI,M.D. 07/01/2020 PAUL J.CANNIFF,D.M.D. THOMAS A.MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable it Inspectional Services BARNS TABLE l4iRx5TnBLE•RN639-2•[ONR•tY4Af:15 WSTMIS x1LS•05�0.VRLE%•fF.Si 84Wa5 E 1639-2014 Public Health Division �Dg �.: I BAMETnaM 1 Thomas McKean, Director MAS& Eo 39. 200 Main Street, Hyannis,MA 02601 ' Office: 508-862-4644 Fax: 508-790-6304 �5 r:. APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE c+ HAZARDOUS MATERIALS ' IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st—JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 RVS-1 CATEGORY 2 PERMIT`. 1.11 —499 Gallons: $125,00. ecic'OK—, CATEGORY 3 PERMIT 500or more Gallons: $150.00 El *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. , 2. IS THIS A PERMIT RENEWAL? YES NO. IF YES, SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF • GREATER THAN HOUSEHOLD QUANTITIES(25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: .:,_) 5. NAME OF ESTABLISHMENT: I l e— COL e.- I�q 6. ADDRESS OF ESTABLISHMENT: �.`5 o rs 16 ris 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: �1 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: t Ci) S 10. SOLEOWNER: YES_NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADD S,y�ND TELEPHONE#OF: CORPORATION-iAD, PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY- NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE Q\Application Fonns\Haz Mat Appli Draft Jan201 .docx �� 1�(Y� ,�»dl Number Fee 1138 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that VILLAGE MINI MART 135 ROUTE 149, MARSTONS MILLS, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. Restrictions: .------------------------------------------------------------------------------------------------------------------------------------------------------------------. This license is granted in conformity with the Statutes and ordinances relating there to, and expires 06/30/2021 unless sooner suspended or revoked. ---------------------------------------- JOHN NORMAN DONALD A.GUADAGNOLI,M.D. 07/01/2020 PAUL J.CANNIFF, D.M.D. THOMAS A.MCKEAN,R.S.,CHO Director of Public Health f` �;,•e .fix. Town of Barnstable Inspectional Services p BARNSTABI;E wit •J1._ WNSTn ' 1Et-MN Ia-ceTUr-AKNIS V 'I-JY MiiSRI!!S M'1LS s DSEMLI-YAF BA�S5, E Public Health Division 1639-2014 8MMSTABLF, 1 Thomas McKean, Director KAM o 39- 6. 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax:�•508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE y"6 HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st—JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 R V CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 611— CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charge of$10 00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO 2. IS THIS A PERMIT RENEWAL?✓SYES_NO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGEIUSE OF GREATER THAN HOUSEHOLD QUANTITIES(25 GALLONS)? AYES NO. 4. FULL NAME OF APPLICANT: � U 4eji 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: t3- P60,e PO t N WJ /V'17I MA 0-2W /1� J 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: rv�As' 8. TELEPHONE NUMBER OF ESTABLISHMENT: Lido-, ©`�- �' 9. EMAIL ADDRESS: 13- (- ho-fit, 10. SOLEOWNER:C/ YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME C re— D6 b 54 C..- PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLIC DATE Q 6 2`L�yp Q:\Application Fonns\laz Mat Appli Draft Jan2019.docx f17Jn� `BIKE►oy� Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 B"M `E 200 Main Street• Hyannis, MA 02601 ta,q. TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT rF0 MP'� Business Name: V11 I xiat i mqa Date: 0 6 Location/Mailing Addres • U Contact Name/Phone: Inventory Total Amount: CSD O SIDS: /S License#: u Tier II : NO Labeling: .- OK Spill Plan: f Oil/WaterSeparator: N 0 Floor Drains: _ A10 Emergency Numbers: Storage Areas/Tanks: 000 o &rSPA Emergency/Containment Equipment: Waste Generator ID: Waste Product: Date&Amount of Last Shipment/Frequency: NIA Licensed Waste Hauler&Destination: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS RO Raja( -C Q, Involoh`� NOTE: Under the provisions of Ch. 111, Section 31, of the General Las of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. N/ Antifreeze jo Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) V Windshield wash 20 y, 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: it ` �`rh10 Inspector: Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY- BUSINESS Number Fee 1138 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that VILLAGE MINI MART 135 ROUTE 149, MARSTONS MILLS, MA Is Hereby Granted a License For: Storing or Handling 111 -499 gallons of Hazardous Materials. ------------------------------ - ------ - -------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2020 unless sooner suspended or revoked. --- --------------------------------- PAUL J.CANNIFF, D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2019 JUNICHI SAWAYANAGI THOMAS A. MCKEAN, R.S.,CH() Director of Public Health Town of Barnstable �. SHE Inspectional Services BABSTABLE f0..� w wsrne=.a+rc.mi•cman•e.nnai= O Public Health Division °s"�"°�5:;�2o< C-4 ABLE, Thomas McKean, Director0-1 plEo ,�a 200 Main Street, Hyannis,MA 02601Co Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS ` IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS DULY 1st-JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 E1 CATEGORY 2"PERMIT r11 499 Gallons: $125.00 " T tf�T�, C116tr CH to CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charize of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. �--�-S "0 2. IS THIS A PERMIT RENEWAL? i,/ S_NO. IF YES, SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: L w-z - 6AS4T 5. NAME OF ESTABLISHMENT: Y 1 t LA G )/�1, M T 6. ADDRESS OF ESTABLISHMENT: R6yk W- MU1T` ( M 0 I A" o 7. MAIMING ADDRESS (IF DIFFERENT FROM ABOVE: 8. TELEPHONE NUMBER OF ESTABLISHMENT: qon-0 r O 9 9 S oe 9. EMAIL ADDRESS: it 1,aL � � 10. SOLEOWNER: c/YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE# OF: CORPORATION NAME St16pD-til A��T/ 53 81®4 - r IYt�t s�i�°eP,�►9 o2�t/9 PRESIDENT��� ;�8 �3 b�-- q'�9�T TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE �� I Q:\Application Fonns\Haz Mat App Revised 09-10-18.docx Number Fee 206 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that Village Garage Inc. 135 Route 149, Marstons Mills,MA Is Hereby Granted a License For: Storing or Handling 111 -499 gallons of Hazardous Materials. ----------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2020 unless sooner suspended or revoked. PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2019 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health ' oewr� of BTstable gala ory Services Richard V. Scah, Director �t�r • Public Health Division BARNSTABLE eniWSraxlE•:[u1ER+nuE•cmurt•xrnn;aS �grABLE. Thomas McKean, Director 1639?20 q fistec?xsr48 E 'ArE1639. 200 Main Street, Hyannis,MA 02601 575 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1st—JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 ❑. CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 ,gV S CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ �� *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? VIYES_NO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS • ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: 5. NAME OF ESTABLISHMENT: 11 1 G G , 6. ADDRESS OF ESTABLISHMENT: ' 35, 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: J 62 I -C /�� r) . c �>M 10. SOLEOWNER: V YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME V I e. PRESIDENT — -Q TREASURER CLERK 12. IF PREPARED BY OUTSIDE PART NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE 0 I ! QAApplication Fonns\HAZMAT APP 2017 REVISE .docx fINE Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 ABLE. • 200 Main Street• Hyannis, MA 02601 1639. o TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: Vlme i1' , % mki Date: il� , I. Location/Mailing Address: k.5 mike, 14q Contact Name/Phone: 150 "4;10—OW Inventory Total Amount: SDS: Qrc�f Im License#: OY Tier II : A Labeling: Spill Plan: Oil/Water Separator: N Floor Drains: 0 Emergency Numbers: Storage Areas/Tanks: KO Emergency/Containment Equipment: eeG lcu, Waste Generator ID: J Waste Product: — NIA Date&Amount of Last Shi ment/Fre uenc Licensed Waste Hauler&Destination: IV 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 10 Dry cleaning fluids �G Automatic transmission fluid Other cleaning solvents&spot removers EEi E gine and radiator flushes Bug and tar removers ydraulic fluid (including brake fluid) Windshield wash Id 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: ft,►1 i`lIM�kLtZC Inspector: Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS tKETo Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 • snRM SS LE. • 200 Main Street• Hyannis, MA 02601 t65 9 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT rF0 MPS s Business Name: , 14- e- M, VX. Aa,r Date: 6 Location/Mailing Address: 13S 1(-q , /i5 Contact Name/Phone: to v s S6>6-q7-0- a. itvf k,� Inventory Total Amount 'tsL9 'Lt"� MSDS: IJa License#: Tier II : 0 Labeling: C�- ��� ��\?�- ` Spill Plan: D- oSh-d Oil/WaterSeparator: A Floor Drains: o Imergency Numbers: Storage Areas/7anks: 3- G'K 5o\ewe. V - 3A4, oQ25c Y'� Emergency/Containment Equip ent: CLVO-Aakol.a, -O%JC Waste Generator ID: Waste Product: 6L5 lo.M•5�r Date&Amount of Last Ship nt/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: ,A1I LIST OF TOXIC AND HAZARDOUS MATERIALS Iv p j�kA joe 4&0k,-�k I K t KV17V V<1q s\k.c..c- �gglr �V.5 P�Ckiov�, NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous/material use, I 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 k ,� Cesspool cleaners Diesel fuel, kerosene, #2 heating oil QS Z 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: wl0vC4 4tov.l-r0 A<kawk3 % v *A k v.- osk•e�? off- �.�.(._, o aJ�•\abt � d, a 2G y ORDERS: Savk a -e-� w..►5 1pC_ �C,'S c a a 1 as5 wk5-EQ.Wd 'S i lavn. avl s,4 e , V 14 a �d�e e 1 •e 1r�� o INFbRMATION/ ECO M NDATIONS: G,x ey�.e-rCkv"'- vw�,P 5ti1 �ow�j Inspector: aw,01Z ��.�` �ee.g. 1 . L Facility Representative: 7 WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS r pU IKE►ot Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-7s0-6304 BA RP- 200 Main Street• Hyannis, MA 02601 �'°rFOMP+A`0 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: Date: .2 ;Lb d� Location/Mailing Address: 135- V4Qt-e- 14.1 Contact Name/Phone: 5 o\ooAl-- l igvt� .508- Y2c7 - 0-F-7 InventoryTotal Amount:^' 0� �\ i i 3 O � MSDS: �1 .4 License#: Tier II : N o Labelina: a eo,\ W� Spill Plan: �e Oi[/Water Separator: r1i Floor Drains: o mergency Numbers: 1 k 1 Storage Areas/Tanks: 'J bo I -3ooa a k e-"L1 Emer enc /Containm nt E ui ment: 6 p e-g' N Sfo! OM,1�°l 5?,1115 '%<V«,L say Waste Generator ID: o c. Waste Product: Date&Amount of Last Shipment/Frequ ncy: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: \ LIST OF TOXIC AND HAZARDOUS MATERIALS !U a y��,o,( I\n.Ikv, NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous aterial use, 3 t e/c q, 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: I ' 0 S �`\ CO�I�� 1Gt.VL ND S aNj 6", A,0 �. ORDERS: 6p vk-,tA e- CDC O� ilvl INFORMATION/RECOMMENDATIONS: Inspecto . , L-e,J e \e-, Facility Representative: ,42 WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS TOWN OF BARNSTABLE Date: TOXIC AND HAZARDOUS MATERIALS FORM NAME OF BUSINESS: V% «age. MIA �atk BUSINESS LOCATION: 13S IL+a M. INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: Sib okL fjasyL� ( Mort Ad EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: w owrL4.r INFORMATION / RECOMMENDATIONS: `�l�o ;z�olo-�,� o� WzA,4o��Qcn�s Fire District: ,a,\o,,k Oozk Co z 5 D5 51,.0�1� �� m� C-o- ,nMVVL PAfS4 Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: a to Product: Licensed? Yes No Oyu� q�c OTE: Under the provisions of Ch. 111,�Section 31, of the Ge eral Laws of MA, hazardous material 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 3D Antifreeze (for-gasoline orcoolant systems) Miscellaneous Corrosive ❑ NEW<�IX�SLD Cesspool cleaners I Automatic transmission fluid '1 Disinfectants I Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) I Refrigerants Motor Oils x' rtAjk +- l_t3 Pesticides I 'llo ❑ NEWI'(,I❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous 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 I Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes y o��vu.e. Laundry soil &stain removers (including bleach) C 4rk L)`1I cAj,Q� "x}k� re- Spot removers&cleaning fluids TJL (dry cleaners) a60kW-1 P&5jk yb2S:: �- eA Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initial Number Fee 1138 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that VILLAGE MINI MART 135 ROUTE 149, MARSTONS MILLS, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. -------------------- ----------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2019 unless sooner suspended or revoked. ---------------------------------------- PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2018 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health T6C 's f(:g-.,y 4 nsla • Voengatory%TervIces B le rqy Richard V. Scali,Director �t� Public Health Division E*: mmurABM Thomas McKean,DirectorMASS.E ` 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st—JUNE 3 Oth). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 I/•S CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? V YES_NO. IF YES,SHIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES(25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: gy/ptm 5. NAME OF ESTABLISHMENT: v C IC ni 1)1' mor� 6. ADDRESS OF ESTABLISHMENT: tq-,� R m9e---- t/ko , nt , M,r°11 i 444 U*y ie 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: Iq 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: 10. SOLEOWNER: i'ES_No IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELVPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK 43hfM 12. IF PREPARED BY OUTSIDE PARTY: • NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICAN Q: -DATE—LEA/ /V �Application Forms�HAZMAT APP 2017 ISED.docx l it Number Fee 206 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that Village Garage Inc. 135 Route 149, Marstons Mills, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2019 unless sooner suspended or revoked. ---------------------------------------- PAUL J.CANNIFF, D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2018 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health r Vowl of Barnstable 0 17g1 y eg atory ervices Richard V. Scah,Director #BARNSTABILE i"e rPublic Health Division BARNSrABLE. Thomas McKean Director MA$$. 1-- 1 59. 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st-JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26- 110 Gallons: $ 50.00 El CATEGORY 2 PERMIT 111 -499 Gallons: $125.00 0 V.S. CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? V/YES_NO. IF YES, SHIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF • GREATER THAN HOUSEHOLD QUANTITIES(25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: UUA 6 4 n 5. NAME OF ESTABLISHMENT: K1 ,11—a Q/"Q !!x e, Lti e, 6. ADDRESS OF ESTABLISHMENT: 13 5 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: 8. TELEPHONE NUMBER OF ESTABLISHMENT: r 9. EMAIL ADDRESS:j 1p rlo / e e (:D M,5,o ,CO rr 10. SOLEOWNER: i/ YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME i' ot7 e, &a ra e- ..L n PRESIDENT �'Oh h 'e 2. 1702 Dx r ° In# 6 (� TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE U Q:Wpplication Forms\I-IAZMAT APP 2017 REVI D. ocx Number Fee ' 1138 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that VILLAGE MINI MART 135 ROUTE 149, MARSTONS MILLS, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. ----------------------------------------- ----------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2018 unless sooner suspended or revoked. -------------------------'------------ PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2017 JUNICHI SAWAYANAGI THOMAS A. MCKEAN,R.S.,CHO Director of Public Health ZZ: d '�iwr t B stable e ato emce8 g zY d . . Richard V. Scah,Director dill �THE r, ''' Public Health Division BAMSTABLE aAMS aaMLMM t% = Thomas McKean,Director �p v 019. ►`� 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 �T `" �d�b Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER'108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1st—JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 CATEGORY 3 PERMIT 500 or more Gallons: $150.00 D *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? YES^NO. IF YES,SHIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONINGBUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGEMSE OF • GREATER THAN HOUSEHOLD QUANTITIES(25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: 5. NAME OF ESTABLISHMENT: �I� � _ mjl rot 6. ADDRESS OF ESTABLISHMENT: 14.1 r (KAY 14g Mif)) ,Aid 626Yg 7. MAILING ADDRESS 0 DIFFERENT FROM ABOVE: S. TELEPHONE NUMBER OF ESTABLISHMENT: - ' 9. EMAIL ADDRESS: (Aa + 05'Ct6 10. SOLEOWNER: 1--YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME Cep PRESIDENT Sums, TREASURER ►P t� CLERK-'CLERK-10cq Rusy+ rj-x.w�j / Mao; ee , vja&ti Aisy-vt4 . 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLIC DATE D Q:1Application Focros\HAZMAT APP 2017 REVISED.docx Number Fee 1138 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that VILLAGE MINI MART 135 ROUTE 149, MARSTONS MILLS, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. --------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------. This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2017 unless sooner suspended or revoked. --------------------------------------- gWAYNE MILLER,M.D.,CHAIRMAN PAUL,J.CANNIFF,D.M.D. 06/30/2016 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health • • Town of Barnstable Ft ►a,� Regulatory Services Richard V. Scah, Director U'"A&A.& `" MASS.�' MS. A' Public Health Division '� BARNSTABLE MASS. UhRNS'POLE•CENiERVILLE•C-11!9 <Mi;i A 16Jy. p�0 �.r gMS'OHSM!L'S•05TEaY:1E•V!EST 2R!Ji5iA8LE rEDN1P� Thomas McKean, Director �; big` 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 A APPLICATION FOR PERMIT TO STORE AND70R UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY lst-JUNE 30th). APPLICATION FEES CATEGORY I PERMIT 26— 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 CATEGORY 3 PERMIT 500 or more Gallons: $150.00 /❑ • A late charge of$10.00 will be assessed if payment is not received by July 1stt.,, ASSESSORS MAP AND PARCEL NO. DATE FULL NAME OF APPLICANT: NAME OF ESTABLISHMENT: AAAq,4-- .ADDRESS OF ESTABLISHMENT: �7� ��,1�. (��I /� &PYOTOS 44")1S, 411, MOO? MAILING ADDRESS (IF DIFFERENT): TELEPHONE NUMBER OF ESTABLISHMENT: ✓ y 2sD '0 EMAIL ADDRESS: 11 f I L ► -h t "rf Of Po hotyxal/, G&,, SOLE OWNER: _12VES_NO IF NO,NAME OF PARTNER: FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME 6Wir Ppf4' VYAC PRESIDENT TREASURER CLERK ry i3 i IF PREPARED BY OUTSIDE PARTY: • SIGNATURE OF APPLICANT Name: �s Company Address : Telephone#: Email: Q:\Application Forms\HAZZAPP Rev I6.docx Page 1 of 2 Town of Barnstable Office: 508-862-4644 Fax: 508-790-6304 i Regulatory Services Department rsrrn�it� Public Health Division MAW.- Thomas A.McKean,CHO 200 Main Street, Hyannis, MA 02601 Payment Receipt ',Hazardous a dous Materials Payment received: $125.00 (Check) on 6/1/2016 Permit number: 1138 .Check number: 2447 Check amount: $125.00 Name on check: Village Mini Mart&Gas Business: VILLAGE MINI MART Owner: NICK I &ROBIN H TRS Address: 135 ROUTE 149, Marstons Mills Note: Category II ...._...._ • III V\ \ �\ Fee �\ Number 1138 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that VILLAGE MINI MART 135 ROUTE 149, MARSTONS MILLS, MA Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2016 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 07/01/2015 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health i Town of Barnstable Regulatory Services Richard V. Scali,Director B Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO. D f ✓V 12—ODATE APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT �j U � NAME OF ESTABLISHMENT C Pf L4 A64 AEI 11 W M41"AU' 41AP`r • ADDRESS OF ESTABLISHMENT 13S kovk N-1 t qt ✓S '►S TELEPHONE NUMBER 99' LI 20- �- SOLE OWNER: DES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL. PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. Z OCR 0 9 STATE OF INCORPORATION M FULL NAME AND HOME ADDRESS OF: PRESIDENT -6Y-/49m &93r - Ra ,P�l� M-IS4*, M4-- &V 9 TREASURER CLERK SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS PC6L AWE A10011sel.oil VU119 HOME TELEPHONE# ::J�— 36,7-13 f,% C:\cache\Temporary Intemet Files\OLKW AZAPP Rev2015.DOC n Town of Barnstable Office: 508-862-4644 Fax: 508-790-6304 o Regulatory Services Department ; ABLE Public Health Division v� z Thomas A. McKean,CHO a Mph a 200 Main Street, Hyannis, MA 02601 Payment Receipt Hazardous Materials Payment received: $100.00 (Check) on 6/17/2015 Check number: 2134 Check amount: $100.00 Name on check: Village Mini Mart&Gas jBusiness: Cape Deli Inc DBA Village Mini Mart Owner: NICK I &ROBIN H TRS MAHAIRAS :Address: 135 ROUTE 149, Marstons Mills 1 � i i i • I Number Fee 1138 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that VILLAGE MINI MART 135 ROUTE 149, MARSTONS MILLS, MA Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 6/30/2015 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 6/30/2014 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable �pfrINEro Regulatory Services Richard V. Scali, Director B"MSTA MASS. Public Health Division '0rfo 39. 0. Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO. DATE APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT "1V E ��t ynt C NAME OF ESTABLISHMENTPM \J I JL"jC Mimi to 4 ADDRESS OF ESTABLISHMENT N 9 r0*20-0 011 M4- 605 TELEPHONE NUMBER SOLE OWNER: �- ES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION. FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER CLERK SIGNATURE OF APPLICANT I RESTRICTIONS: HOME ADDRESS ' Aw alY 4" Cz6Y5 HOME TELEPHONE# - 939 0 Q:\Application FormMAZAPP.DOC Number Fee 206 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that Village Garage Inc. 135 Route 149, Marstons Mills, MA Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 6/30/2015 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER, M.D.,CHAIRMAN PAUL J.CANNIFF, D.M.D. 6/30/2014 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health i Town of Barnstable oFTHE r Regulatory Services Richard V. Scali, Director 9'"M S. * Public Health Division i639. �ArF039 4 Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO. DATE APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS { FULL NAME OF APPLICANT �Jb�VL V NAME OF ESTABLISHMENT V ADDRESS OF ESTABLISHMENT ��i� 4 TELEPHONE NUMBER 9 SOLE OWNER: YES VNO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO.O 4-3 STATE OF INCORPORATION FULL NAME AND HOME`ADDRESS OF- PRESIDENT -e Py-w-5\' (Ae.Ok- b- fir+ �o�1,�u ►�1 Y TREASURER i5�b CLERK SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADD SS HOME TELEPHONE# J:V-IAZAPP.DOC I' SPILL CONTINGENCY PLAN Emergency Coordinator,Name: ( In�} Address: ax R. i I?.Q D n-- Daytime Phone: — Evening Phone: Fire Department: Barnstable Public Health Division: 508-862-4644 DEP 24 Hour Spill Hot Line: 888-304-1133 Waste Mauler: Name: A.MA,t--A iT�/ ��V5 Phone: Building diagram indicating hazardous material/waste storage area, location of absorbent scavenger materials, fire extinguishers, fire alarms (if present), and evacuation route (if applicable). JRM AIA S IN L40i My IAI MUN6 MY Q2 d A 73AN ftj z � NOt k�l�'t L kEA lQrY SHOP � t 1 Q T cats �EAV A 1 A 3 8AV Actions to be taken to control a spill or release and preventi g it from reaching a catch basin, sewer system or the ground. Corvz-.all� m+�n - 3goom s RQ, EACu OIL SMRA6C unn S I!3J V1 RL I M a' 5 6L5 a SS CRILonr B9RR4L 5 90 IV070S ©e MAJ SAWY Ae�K /N A AAM6L PWs a SIG sNoV'u-s A'mo 'Q Azcs# S&opens foR fMISLE C'!.&4N— ZIP5 Number Fee 206 THE COMMONWEALTH OF MASSACHUSETTS $100.00 Town of Barnstable Board of Health This is to Certify that Village Garage Inc. 135 Route 149, Marstons Mills,MA 02648 Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. ----- --- - _ - . -- - .. . . .._. . . - --- ------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 6/30/2011 unless sooner suspended or revoked. ----- ------------- WAYNE MILLER, M.D.,CHAIRMAN PAUL J. CANNIFF, D.M.D. 6/30/2010 JUNICHI SAWAYANAGI ......_ ._- ------ ........... .... THOMAS A. MCKEAN, R.S.,CHO Director of Public Health Town, of Barnstable zw�y Regulatory Services r _.. Thomas F. Geiler,Director • 4 Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508=862-4644 Fax: 508-790-6304 Application-Fee,-$1-00 00 ASSESSORS MAP AND PARCEL NO. DATE APPLICATION.FOR PERMIT.TO.STORE,AND/OR UTILIZE.MORE.THAN. 111. GALLONS.OF.HAZARDOUS MATERIALS FULL NAME OF APPLICANT --- NAME OF ESTABLISHMENT VI ,I�_Qp ADDRESS OF ESTABLISHMENT 4 135 -'lq3 RTE 1 9 � TELEPHONE NUMZ R 'Tc�' �--� •SOLE OWNER: YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF AL t� PARTNERS: AUG, 2� 6 RECD LF3 y IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. 44 STATE OF INCORPORATION AR �YA FULL NAME AND HOME ADDRESS OF: PRESIDENT 1 TREASURER CLERK IGNATURE OF APPLICANT RESTRICTIONS: HOME ADD SS / 17 HOME TEL' PHONE# �- e azaoc/wp/q MAIL-IN REQUESTS • Please mail the completed application form to the address below: Also include c lude a copy of your contingency plan (to handle hazardous waste spills, etc). In addition; please include the required fee of$100. Make check payable to: Town of Barnstable. Allow five to seven (7)working days for in- house processing. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis,MA 02601 FOR FAXED REQUESTS Our fax number is (508)'790-6304. Please fax a completed application form. Also, please fax us a copy of your contingency plan (to handle hazardous waste spills, etc). In addition, please mail the required fee amount of$100.00. Please make the check payable to: Town of Barnstable. The check must be mailed to the address listed above. Allow up to four days for in-house processing. For further assistance on any item above, call(508) 862-4644 • f S PI L L • CONTINGENCY PLAN Emergency Coordinator, Name: J Ofliq Tr-c Address: XECRO - Daytime Phone: Evening .Phone: Fire Department: Barnstable Public Health;Division: 508-862-4644 DEP 24 Hour Spill Hot Line: 888-304-1133 Waste Hauler: Name: --60&f IA )C16147 Phone: _r1�i-, � -- ��9 IPACCIZ 97g_g5 801 Building diagram indicating hazardous material/waste storage area, location of absorbent scavenger materials, fire extinguishers, fire alarms (if present), and evacuation route (if applicable). AWAIS IN 6404 SqY 1N ,fC1L11116 • eENcH V[R(r 0 i L FR�tS i�JU 04 BATk ROOM L �� a klA OIL A I � } MWER SAY 3 SA Actions to be taken to control a spill or release and preventing it from reaching a catch basin, sewer system or the ground. CoN-"A10 m EO FOB. EAC44 0IL STORAC.;,[7 0/)dTS . V d RG I N 6?�S GL5 t>? —55— CALL-01 &IRR4LS (� P00170�5 0,&' A/�-tJ SPZ�"C�y &YIV /W A &9,0 6' - PLUS" 4�7 .816 51410 i&L6 4AI-0 --V PZ<511 6ROLIA)_5 �55:5,496' if .�41V-- SIP Number Fee 1138 THE COMMONWEALTH OF MASSACHUSETTS $Ioo.00 Town of Barnstable Board of Health This is to Certify that VILLAGE MINI MART 135 ROUTE 149, MARSTONS MILLSMA 02648 Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. 00 - -------------------------------------------------------------------------------------------------------------------- ------------------------------------ ----------------------------------------------------------------------- -------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 6130/2014 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 4/1/2014 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable Barnstable 'THE Regulatory Services Department Public Health Division RARNSrABLL I iMAS& 200 Main Street, Hyannis MA 02601 1639. � A 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO. DATE �� / `/ APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE i MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT �'q6UP� A015-n� r nA NAME OF ESTABLISHMENT In.4-6r /'11�j� lmizi ADDRESS OF ESTABLISHMENT (� °1LY I U 9 ,, M4PRVV A�i�lst/hr} 48 TELEPHONE NUMBER �� lI SOLE OWNER: LEES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF.APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION �yl FULL NAME AND HOME ADDRESS OF: PRESIDENT 5t4,3tPY rMo nkvq TREASURER CLERK SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS HOME TELEPHONE# 44 J:\inspection handouts\Haz Mat Application2008.DOC. f MAIL-IN REQUESTS Please mail the completed application form to the address below. Also include a copy of your contingency plan (to handle hazardous waste spills, etc.) In addition, please include the required fee of$100. Make check payable to: Town of Barnstable. Allow time for in-house processing. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 FOR FAXED REQUESTS Our fax number is (508) 790-6304. Please fax a completed application form. Also, please fax us a copy of your contingency plan (to handle hazardous waste spills, etc.) In addition, please mail the required fee of$100. Please make the check payable to: Town of Barnstable. The check must be mailed to the address listed above. Allow.time for in- house processing. For further assistance on any item above, call (508) 862-4644 Back to Main Public Health Division Page JAinspection handoutsUiaz Mat Application2008LOC I i SPILL, CONTINGENCY PLAN Emergency Coordinator, Name: Address: Daytime Phone: Evening Phone: Fire Department: Barnstable Public Health Division: 508-862-4644 DEP 24 Hour Spill Hot Line: 888-304-1133 Waste Hauler: Name: Phone: Building diagram indicating hazardous material/waste storage area, location of absorbent scavenger materials, fire extinguishers, fire alarms (if present), and evacuation route (if applicable). I i Actions to be taken to control a spill or release, and preventing it from reaching a catch basin, sewer system or the ground. Number Fee 206 THE COMMONWEALTH OF MASSACHUSETTS $loo.00 Town of Barnstable Board of Health This is to Certify that Village Garage Inc. 135 Route 149, Marstons Mills,MA 02648 Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- . This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 6/30/2014 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 10/18/2013 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health 1 Fr Town of Barnstable Barnstable Regulatory Services Department ANUUMicacly . Public Health Division `+ MAMSTast F. ' "AS& 200 Maul Street, Hyannis MA 02601 1679- 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO Application Fee: $100.00 i ASSESSORS MAP AND PARCEL NO. DATE APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT VILLAGE CAEA G E -%l C. NAME OF ESTABLISHMENT I/OLL A G,E -,C�C'� 1'/1l ADDRESS OF ESTABLISHMENT / lizE &Z NTM AICL-7 od4qa TELEPHONE NUMBER 509' !%29- �/ SOLE OWNER: YES '41 IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. O � STATE OF INCORPORATION—IS�, 'C (L�, FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER L�AlnejCIA OAG!� C,,=&-r g,35 CLERK 4' SIG A F APPLICANT RESTRICTIONS: HOME RESS �X �,p/!/e��/�Tt/1T has HOME TELEPHONE# J:\inspection handouts\Haz Mat Application2008.DOC IR d I ' SPI L L CONTINGENCY PLAN Emergency Coordinator,Name: J-11H N RoTgE Address: M Daytime Phone: Evening Phone: Sf�S• Sfo? -Lgq, _ Fire Department: Barnstable Public Health Division: 508-862-4644 DEP 24 Hour Spill Hot Line: 888-304-1133 Waste Hauler: Name: Phone: - Building diagram indicating hazardous material/waste storage area, location of absorbent scavenger materials, fire extinguishers, fire alarms (if present), •oute (if applicable). 1 A1.4MS IN EACH 64 y /tv C'UNG Vt N 01 L IMl ��- P - wN t, -n+��' v Z £ v s aLB 03AA Not ; w L L /QyY SHOP 6 WAMr®/L f � � � �•�' �a�ieEcs EAC A 3 'BAY Actions to be taken to control a spill or release and preventitig it from reaching a catch basin, sewer system or the ground. (20NTA1J) MEvr doom I:i)R, E'ACA Ott, SMRA6C UnM (3, 90 )E 01705 v-& AIW SM50Y Mlo" /N A AAK-61, RUS .816 .5A10VaR-S Arun Q Pam# -SROP -5 r-OR - f�5sr8L�' e!�4tV- �ip5 w MAIL-IN REQUESTS Please mail the completed application form to the address below. Also include a copy of your contingency plan (to handle hazardous waste spills, etc.) 1n addition;please include the required fee of$100. Make check payable to: Town of Barnstable. Allow time for in-fuse processing. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis,MA 02601 FOR FAXED REQUESTS Our fax number is (508) 790-6304. Please fax a completed application form. Also, please fax us a copy of your contingency plan (to handle hazardous waste spills, etc.) In addition, please mail the required fee of$100. Please make the check payable to: Town of Barnstable. The check must be mailed to the address listed.above. Allow time for in- house processing. For further assistance on any item above, call 508 862-4644 Back to Main Public Health Division Page JAinspection handouts\Haz Mat Application2008.DOC CENTEFMLLE-OSTERVILLE-MARSTOINS pi(jo FIRE DEPARTMENT 999 Main Street Osterville,Mass.O2655-2018 Tel.428-2467 � C V � F.P. 292 • Department of Public Safety—Division of F)re Prevention APPLICATION FOR PERMIT FOR REMOVAL AND TRANSPORTATION TO APPROVED TANK YARD 91� 19 C.82 S.4O M.G.L. To: HEAD OF FIRE DEPARTMENT DIG SAFE NUMBER CiM w Tww Start Date In accordance with the provisions of Chapter 148, G.L. as provided in Section 38A Application is hereby made by Name of Person,Firm or orpora lon) ouo `l A b M Address Ov O For permission to remove and transport underground, steel storage tank(s) from Street adaress city o'r town FDID#(� �� (� �to approved Tank Yard!,' _ Y State clearly type of inert gas used in AllT/toS-�--� steel storage tank Typeofinert gas use Name of Person, Firm, Corporation disposing tank— e,o-,,,i /fgr.�ria Date ssu - rejected y' Lz 19 B Date os expiration 19 �ti�&/due ture o pp/scant Data Chart for Tank System Tightness Test pktr® Tate PLEASE PRINT TANK TESTER i 1. OWNER Property vyt.t� JCxi)C13[ o`l� ov - /1/9 yl..F�/ Name Address Representative Telephone Tank(s) j>p1-JA'l-p Ef}CkE Y . Name Address Representative Telephone 2. OPERATOR ID ,/AA,b Mc C-) cCkr &-' reo re /vf A),/q?STnv ILLS S` f P",- Name Address Telephone 3. REASON FOR Z/../V of �;r/s/i�naN BoA9,0 TEST �,✓a� c ���7 (Explain Fully) - ---- 4. WHO REQUESTED TEST AND WHEN Name Title Company or Affiliation Date Address Telephone 5. WHO IS PAYING _ FOR THIS TEST? Company,Agency or Individual Person Authorizing Title Telephone Billing Address City State Zip _ Attention of: Order No. Other Instructions Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass 6. TANK(S) INVOLVED dC-fT a ff-p 4Lu =OJT ov-1 4M 06 0 -�L- Location Cover Fills Vents Siphones Pumps 7. INSTALLATION DATA 4M 'yell � �S n�wj 7 4 °2 r fJorth msid drive ay, Concrete,Black Top, Size,Titefill make.Drop Suction,Remote. Rear of station,etc. Earth,etc. tubes,Remote Fills Size,Manifolded Which tanks? Make it known 8. UNDERGROUND Is the water over the tank? WATER Depth to the Water table El�nl,, 7� I// Yes L'f r"o Tanks to be filled hr. Date Arranged by '1&4 Dy/�21 77-5-37/1 _. 9, FILL-UP - Name Telephone ARRANGEMENTS Extra product to"top ff"and run TSTT. How and who to provide? Consider NO Lead. uc Terminal or other contact / ��1gk D 6)/L [/� DVNNL� �s 37/ for notice or inquiry _ Company Name Telephone 10. CONTRACTOR, /�O°D G /C /u t?bG KS RP, /7/y/�'.vrt✓/S _ MECHANICS, any other contractor involved 11. OTHER -.-. INFORMATION _ OR REMARKS . Additional information on any items above.Officials or others to be advised when testing is in progress or completed.Visitors or observers presen during test etc. Tests were made on the above tank systems in accordance with test procedures prescribed for Petro T r 12. TEST RESULTS as detailed on attached test charts with results as follows: TANK TESTEa Tank Identification Tight �{ Leakage Indicated ` Date Tested p 8 Sr-t P/ r p &oco This is to certify that these tank systems were tested on the date(s)shown.Those Indicated as"Tight"meet the criteria established b, 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. Date f Testing Contractor or Company. By: Signature SIAI �v6,c� Serial No.of Thermal Tec icja E� Address Sensor Rc77 is r Y 5' 14. i7o �✓+�o �, MtLAcffeAA/ K nn ou-r IY9 /g/1 7,f Name of Supplier,Owner or Dealer Address No.and Street(s) City State Date of Test D 15. TANK TO TEST 16. CAPACITY From ❑ Station Chart Z DOD capacity most accurate 'DO d ❑ Tank Manufacturer's Chart m ,� 't ��K Nominal Capacity � capacity chart available -N-r ® Identity by position Gallons Gallons ❑ Company Engineering Data � /'/ Is there doubt as to True Capacity 7 ❑ ❑ Charts supplied with �c 1Co utle I®_ Brand and Grade See Section"DETERMINING TANK CAPACITY" Other 17. FILL-UP FOR TEST Stick Readings Total Gallons to c/a in. Gallons ea.Reading Stick Water Bottom before Fill-up / " _ 7 Inventory / UGL L�pDo to t/a in. Gallons Fill up.STICK BEFORE AND AFTER EACH COMPARTMENT DROP OR EACH METERED DELIVERY QUANTITY _ Tank Diameter (o Y Product in full tank(up to fill pipe) `-I 0 8 w C W ® 18. SPECIAL CONDITIONS AND PROCEDURES TO TEST THIS TANK v�S � '� VAPOR RECOVERY SYSTEM G�p� d�� C�v�l✓;;l O0 mac' See manual sections applicable.Check below and record procedure in log(26). / (o P/q✓ r Stage 1 ZCDG Y o PP Water in tank ❑ High water table in tank excavation ❑ Line(s)being tested with LVLLT ❑ Stage II >$m 0 21. TEMPERATURE/VOLUME FACTOR (a) TO TEST THIS TANK 0 19. TANK MEASUREMENTS FOR TSTT ASSEMBLY Is Today warmer?[J Colder?:_ F Product in Tank °F Fill-up Product on Truck F Expected Change ( + or - ) ry CD Bottom of tank to Grade*.................... " 7 CD digits�Q 22. Thermal-Sensor reading after circulation 111 0 9 7earest OF Add 30"for 4"L OD —. Add 24"for 3"L or air seal ....... 23. Digits per OF in range of expected change— Total tubing to assemble Approximate digits n r� 20. EXTENSION HOSE SETTING 24. yoo X ,c,GG(c 5`/7 — .la ,3 �SZ gallons total quantity in coefficient of expansion for volume change in this tank Tank top co grade .................................. J - 2- " full tank(16 or 17) involved product per IF Extend hose on suction tube 6"or more C.� below tank top ..................................... U 25. �r w1�0 1, _ .> -�S _ n 0 0 �r�9/ This is volume change per OF(24) Digits per OF in test Volume change per digit. test If Fill pipe extends above grade,use top of fill. Range(23) Compute to 4 decimal places. factor(a) 26. 30. HYDROSTATIC 31. 34. 38.NET VOLUME 39. VOLUME MEASUREMENTS(V) TEMPERATURE COMPENSATION ACCUMULATED CONTROL EACH READING LOG OF TEST PROCEDURES PRESSURE RECORD TO.001 GAL. USE FACTOR(a) CHANGES CHANGE 27. 28. 29. Standpipe Level 32. 35. 36. 37. Temperature At High Level record inlnches Product in Product Change Computation P Adjustment Total End Deflection DATE Record details of setting up Reading Graduate Replaced(-) Thermal and runningtest. Use full No. Higher+ Ex x (a) = Volume Minus ( Beginning level to Sensor Lower- Expansion+ Expansion(+)or At Low Level compute TIME length of line if needed.) of which Before After Product Reading (c) Contraction - Contraction(-) Change per Hour (24 E Reading Restored Reading Reading Recovered(+) #33(V)—#37(T) ha PA criteria) 7 Q o v �- D 7.27 D7y "t V 7S 76 " 37 z 930 7,20 ,2 /C, ,3Y1, 9/ 7 7 f � T In 3, S' P-0 Okv �o z t GSYS-, t 33 /o o r iYs 7 /{% � / z ,3�6 , y7v d ¢ 8� /3 ti T .003 +- � fi- /� 7S" 2� 95 8.5"� OL r /9v 7/6 7 Ry i✓F/'fi t ,o/S f'l{ ,j/� 14. 'Ppni�4� p �c ,--/7cHc-,OqA) r3y7C (14 /HA?.s7a.✓s /�'iG(.s Name of Supplier,Owner or Dealer Address No.and Street(s) City State Date of Test D� 15. TANK TO TEST 16. CAPACITY From Z Station Chart , -r- /� By most accurate m � � /�S T / /�N/L Nominal Capacity / 000 capacity chart available Y G D G Tank Manufacturer's Chart � ® Identity by position Gallons Gallons D Company Engineering Data m ) /J D �� �L U N L /L, Is there doubt as to True Capacity 7 Charts supplied with �tEO TIfP Stand and Grade See Section"DETERMINING TANK CAPACITY"I� SANK TESTER� Other .-J I.IJ l5- 49A/► 17. FILL-UP FOR TEST Stick Readings Total Gallons to'/a in. Gallons ea. Reading Stick Water Bottom before Fill-up _ Inventory O /�O to% in. Gallons Fill up.STICK BEFORE AND AFTER EACH COMPARTMENT DROP OR EACH METERED DELIVERY QUANTITY /p- _ Tank Diameter `y / Product in full tank(up to fill pipe) ! / Co p .® 18. SPECIAL CONDITIONS AND PROCEDURES TO TEST THIS TANK /, 7 69S l eAv/ ry VAPOR RECOVERY SYSTEM $x X Ch -1 n See manual sections applicable.Check below and record procedure in log(26). p O w> 7/,G C'o FL R, A P) 67,eo9V17y [►�S`tage 1 g Z N M D Water in tank High water table in tank excavation D Line(s)being tested with LVLLT Stage II a8m 0 21. TEMPERATURE/VOLUME FACTOR (a)TO TEST THIS TANK M Q 0 19. TANK MEASUREMENTS FOR ro TSTT ASSEMBLY Is Today Warmer?[l Colder?[I_°F Product in Tank—°F Fill-up Product on Truck_°F Expected Change( + or — ) I o m Bottom of tank to Grade*.................... / m 22. Thermal-Sensor reading after circulation /,5 ��� w °F Co Add 30"for 4"L 3 L7 _." digits 4earest Add 24"for 3"L or air seal ....... " 23. Digits per°F in range of expected change 1�Z Total tubing to assemble Approximate ......... / / " digits 20. EXTENSION HOSE SETTING 24• yo/D X 'DooG 9 G,5Z - ,-P, 7j,��`�S gallons total quantity in coefficient of expansion for volume change in this tank Tank top to grade................................... full tank(16 or 17) involved product per°F Extend hose on suction tube 6"or more below tank top ..................................... 25. -P, 7/02 This IS volume change per°F(24) Digits per°F in test Volume change per digit, test If Fill pipe extends above grade,use top of fill. Range(23) Compute to 4 decimal places. factor(a) 26. 30. HYDROSTATIC 31. VOLUME MEASUREMENTS(Y) 34' TEMPERATURE COMPENSATION 38•NET VOLUME 39. ACCUMULATED LOG OF TEST PROCEDURES PRESSURE RECORD TO.001 GAL. USE FACTOR(a) CHANGES CHANGE CONTROL EACH READING 27. 28. 29. Standpipe Level 32. Product in Product 35. 36. 37. Temperature At High Level record ro on[ Record details of setting U in Inches Change Computation Adjustment Total End Deflection Reading Graduate Replaced(-) Thermal and running test.(Use fulll No. Beginning Level to Sensor Higher+ Ex x (a)+ Volume Minus length of line if needed.) A of A which Before After Product Reading Lower- Expansion + Expansion(+)or At Low Level compute TIME A (c) Contraction- Contraction(-) Change per Hour (24 hr.) Reading Restored Reading Reading Recovered(+) #33(V)-#37(T) (NFPA criteria) i r 7,90bd a� � ?oSd s /s ,�o'o a / -� 630 960 Est -f/S r j t/S `fZ 7 o d . / YO 26 4- dcf�.S �,z 270 LSD ,� ,� + // y U �o O r GV 7.7- r Z- o v 7,z ' p �/7 2- U 930 , l95 .34s >/ 7o r 67O o2/ t ./,r/ r , oil ys 36� , s'is /Sat U8"7 - t y4 r ,poY t '00Y t /ono Q y,7s' /�- 5iS .G bd -/YS r oY /7 t y& t /0/5 ,, t // /Y-7SZ 16 t •/3R t Dom } os + 030 + ' , ' /� P 1 360 ,�� y`� t /3/o b . 73SI 00.2 � t . 007 /033 oo 4 ti S o 7 J 5 �7 o Ll l� �= 14. �o��� D nl Ae L—rgc 11Ettq Af (la v TL I �y Allll f wlg Nile t.S Z Name of Supplier,Owner or Dealer Address No.and Streets) City State Date of Test D� 15. TANK TO TEST 16. CAPACITY From I� ❑ Station Chart ® By most accurate m / —1l9/J le- Nominal Capacity O d D capacity chart available O ❑ Tank Manufacturer's Chart ® Identity by position Gallons Gallons Company Engineering Data m /�/k d C ��2 Er/1 t Is there doubt as to True Capacity 7 ❑ Charts supplied with F_± rO Tt_fP Brand and Grade See Section"DETERMINING TANK CAPACITY" nNKTrsira �� Other , lcJ (� 17. FILL-UP FOR TEST Stick Readings Total Gallons to'/a in. Gallons ea.Reading Stick Water Bottom .-- before Fill-up _ Inventory to% in. Gallons Fill up.STICK BEFORE AND AFTER EACH COMPARTMENT DROP OR EACH METERED DELIVERY QUANTITY Tank Diameter y Product in full tank(up to fill pipe) t `�o$ w C)00 ® `' 18. SPECIAL CONDITIONS AND PROCEDURES TO TEST THIS. TANK Sa' `''�S ►ZA�!'Ty VAPOR RECOVERY SYSTEM -t 0 ,• See manual sections applicable.Check below and record procedure in log(26). d 3 r tage I aON> S S.� CoRR f,rP/ � 1T(f1tJ / Z N Water in tank ❑ High water table in tank excavation ❑ Line(s)being tested with LVLLT ❑ Stage II �gz N. m w o 21. TEMPERATURE VOLUME FACTOR a TO TEST THIS TANK N 19. TANK MEASUREMENTS FOR o 1 TSTT SSE Is TodayWarmer?[] Colder?U—°F Product in Tank. °F Fill-up Product on Truck_°F Expected Change ( + or - ) . ASSEMBLY BLY N to Bottom of tank to Grade*.. y Z- tp """"""""" 22. Thermal-Sensor reading after circulation G 3 7/ °F Add 30"for 4"L ................. _70 _ digits Barest j Add 24"for 3"L or air seal ....... 23. Digits per°F in range of expected change Total tubing to assemble Approximate ......... 1� y L digits 20. EXTENSION HOSE SETTING 24• VVos x do OS 79s� — �• 3�0?97� gallons total quantity in coefficient of expansion for volume change in this tank /Tank top to grade*.................................. -3 . " full tank(16 or 17) involved product per°F j Extend hose on suction tube 6"or more p . p p below tank top ..................................... d -" 25. of9 r-3oZ eU / 75- s 5 _ . OG',1 y/.Z This is volume change per°F(24) Digits per°F in test Volume change per digit. test If Fill pipe extends above grade,use top of fill. Range(23) Compute to 4 decimal places. factor(a) 26. 30. HYDROSTATIC 31. VOLUME MEASUREMENTS(Y1 34. TEMPERATURE COMPENSATION 38•NET VOLUME 39. ACCUMULATED LOG OF TEST PROCEDURES PRESSURE RECORD TO.001 GAL. USE FACTOR(a) CHANGES CHANGE CONTROL EACH READING 27. 28. 29. Standpipe Level 32, 35. 36. 37. Temperature At High Level record Product in Product DATE Record details of settingD in Inches Change Computation olumem int total End Deflection P goading Graduate Replaced(—) Thermal and running test.(Use full No. Higher— Ex x (a)= Volume Minus length of line if needed.) Beginning level to Sensor Lower— Expansion+ Expansion(+)or At Loa Level compute TIME of which Before After Product Reading (c) Contraction— Contraction(—) Change per Hour (24 hr.) Reading Restored Reading Reading Recovered N #33(V)—#37(T) (NFPA criteria) v3S �S •�z / e 4� a37 17 ,6o�I /30r�� 2 `��,� ,�v�p U3o r Ds3 / 3 y 3.3 . 6 70 ,7 Sa olio 077 ,/ 70 o o 42 693 /6 boy ' y'l,S 2 3/o yo 3o t /2- ys- &S its' ,/�v t /y /Y ' /PYZ C --2 .Cow .7 0 //G /S9 /o /y 1,2 /YO ,270 3 0 / /Y.S ,2 „274 3rS zs .r /� 7 � �/ ,00Yt ooy, t o 3y '` '` ' � /`/• 3 � ,3 s" .S/o . /� s t �oY .S t o t o� r ,ol.z � � yUv �� /`•/ 1,2 . 6loU ./ GS , /oS' �/ + oyo f st ,o.27 t c J TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS t ' NAME ADDRESS ( - VILLAGE LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE: OR CHEMICAL (Give same information for any additional tanks on reverse side of card) DATE OF PURCHASE OF EACH: 1. ! 2 3 �/ �D 4. DATE OF FIRE DEPARTMENT PERMIT: ' TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS - _ i NAIVE RtG'. ��i� - �1VET Rd. Route 10 :.« Mar ;t:,ons 1115 j°ass, Marstors Mills, T sS 160K L PA(' 7 77/?2 5 4'26 , 974 - ' AR 2 01975rpfl -AR 51976 MAR 2 8 i97