HomeMy WebLinkAbout0319 CEDAR STREET - Health 319 Cedar Street, W. Barnstable
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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM �
NAME OF BUSINESS: � fFz Zi9�- Mail To:
BUSINESS LOCATION:;.I f( <IIKJ�6 ? y�� ��a� � Board of Health
MAILING ADDRESS: ,�S' 4 4 t "a Town of Barnstable
P.O. Box 534
TELEPHONE NUMBER: -- l3` Hyannis, MA 02601
CONTACT PERSON: � ,�
EMERGENCY CONTACT TELEPHONE NUMBER:
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in qua tities totalling, at any time, more than 0 gallonsliquid 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 character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
4WAntifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
ydraulic fluid (including brake fluid) Disinfectants
✓! otor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
iesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
Paints, varnishes, stains, dyes Fertilizers (if stored outdoors)
Paint & lacquer thinners PCB's
Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy- Health Department/
Canary Copy Business
ry `'
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body Shops
unsatisfactory- 4.Manufacturers
(see"Orders") 5.Retail Stores
Q COMPANY A�!.fe6.Fuel Suppliers
ADDRESS,Itf ga�y zr � Class: 7 7.Miscellaneous
-� QUANTITIES AND STORAGE (IN= indoors;OUT=outdoors)
MAJOR MATERIALS Case lots Drums Above Tanks Un derg'ro�]�&Trn Os
IN OUT IN OUT IN OUT #&gallons Age Test
i
Fuels:
Gasoline,
z il, 27
Diesel, Kere&wu®;#2(B) ` 7pty
Heavy Oils:
waste motor oil (C)
new motor oil (C)
transmission/hydraulic
Synthetic Organics:
degreasers
h'
TZ-
Miscellaneous:
47
DISPOSAIJRECLAMATION REMARKS:
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1. Sanitary Sewage 2. Water Supply
O Town Sewer OPublic
On-site Private
3. Indoor Floor Drains YES NO
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YES NO ORDERS:
Q Holding tank:MDC J2
O Catch basin/Dry well
O On-site system
5.Waste Transporter
Name of Hauler Destination Waste Product
YES INO
2.
P rs n (s) Infe ewed Inspechof Date
TOWN OF BARNSTABLE
LO ATION SEWAGE #'Z �.
VILLAGEJ�� �[5 ASSESSOR'S M LOT
INSTALLER'S NAME & PHONE NO. `c
I: ..I I
•`S .1l ..
EPTIC TANK CAPACITY ;
~LEACHING FACILITY:(type) r e (size) (�~e
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATEV9,1,;
BUILDER OR OWNER9 9, 2
DATE PERMIT ISSUED:__/ L
DATE COMPLIANCE ISSUED: ���� - 4
,' VARIANCE GRANTED: Yes -No C/
4AIXj -
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LOCATION SEWAGE PERM�,T NO.
WgZ i D ABC rABLG Pd a cetL 'j (e.
x Ste.
VILLAGE uo, M,4R. p,$ �e
P Fc. c-DAR ST u/ QA�1�
INSTA LLER'S, NAME & ADDRESS
B U I'L D E R OR OWN ER J
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y �
DA T E PERMIT ISSUED Id �-_/ems--,7
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH "PROVED
TOWN OF BARNSTABLE owrtn.e
Appliration for Biipnsal Workii Tnnstrurtin �. z
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:� ^� T w:��'S'r /3/ /P /4A
3 ��.___.._�....r .... .. � -�.1 S
..-------• •- - .....-••.......................................... ........................ - - ..................
Location-/C7pJ{ddress �}�—�/�l/J ov Lot No.
.. /.................•----•--...............- -•---....------••-•-• -c--/�/"�""C'•'"S•----.....-----•-•----•---•-•---------..........-----•7Own r Address
Ga
Installer Address
t4 -_
Type of Building Size Lot. ...��e�_Sq. feet
a Dwelling—No. of Bedrooms........................................Expansion Attic 01,y Garbage Grinder
aOther—Type of Building ............................ No. of persons....___..___...._._.._____.. Showers ( ) — Cafeteria
Otherfixtures ------------------------------------------------------•-----------------------------------------------------------------------.-------------•-.------
W Design Flow............................................gallons per person per day. Total daily flow............................................gullons.
WSeptic Tank—Li uid'ca acit _(//&_ allons Length--- Width._. Diameter De tl ___--.
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (1C,.) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
GL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--__•_•----.•-_--_-____-
a -- -• ---------------- •--------- ..... ------ --I.................
O Description -� ��
of Soil___________ __ ,�d 1�
�i
W ---•••••---•-------•-.....--•----•••---•-••-•.....•-•...................•••••---••••••••--•••••••••----•••••••••---•-••--•••••••-----•••---•-•-••••••-••••••-•-••-•••--••....._.._...................••-
VNature of Repairs or Alterations—Answer when applicable._...................................................................•-----------------------__.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia has n 's ed the boartof health.
Signed .. . .- .. ` - ....... � % D..l�......Z.
Dare
Application Approved By ..................... S).
Date
Application Disapproved for the following reasons- ---------------------------------------------------------- ----------------------------------------------------------------------
.
a2....-...v�..-�.?--.....---------------------- Issued ......--.....--........................................ate......
Date
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Fps. ....
THE COMMONWEALTH OF MASSACHUSETTS
_BOARD OF HEALTH
TOWN OF BARNSTABLE
.c� t t�tPFitti�YT for i tit �tl WorksC� n rnrtinln rrm' ' �5a
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: �17 .
..f;?!. Location- ddress Lot No.
�1✓ -----------------------------=------------------
7 Owner Address
................
M Installer r Address
Q7i Type of Building Size Lot..= C��� ....Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic 01), Garbage Grinder ( )
a`4 Other—TYP e of Building -----------'- P............... No. of ersons---5..................... Showers Cafeteria
--------------•-----------•--- ( )•--
Q Other fixtures ................... ( ) r�U
WDesign Flow...........................................gallons per person per day. Total daily flow--__......................................gallons.
WSeptic Tank—Liquid capacity,��l4K.gallons Length...!>......... Width..yST........ Diameter.Z...__.... Depth. .�..........
x Disposal Trench—No..................... Vidth.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..............r------ Diameter._---K.......... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (/ ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date------------------...............------.
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0�4 Test Pit No. 2................minute9 per inch Depth of Test Pit.................... Depth to ground water........................
w -- = =------------- = :..--------------•---------......------•-•--...-----...............................................................
x . Description of Soil----•------�`-�f.!............... i_,-�---•--� rl/ "-----(' _._/
/'d
V ......................................................-•V .
--------•---•--•------------•-------------------...------------. .....------......----------...-----------------------•----------....---......
W �
.......—-----------------------------------------------------------------------,1..............I....--_.._.__......__...----.._.._..........._........_._..............................................
U Nature of Repairs or Alterations—Answer when applicable...............................:................................................................
...--•-----•-----------------------------•----------------•-----------------------•-•--.......-•--••.......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation untiha Certificatit of Compliance has been is -tied by'the board,-of health'.
'---'Dare /,
Application Approved By ------ ail;
--.. .[< »«- ......... /....... /.1..- 3 -...9. .
Date
Application Disapproved for the following reasons- ----------------------------- -------------------------------------- ---------------------------...........................------
------------------------------------- -----..................................................-------------------------- ------------------------ ...................................................... -----------------------------------
Date
PermitNo. ....... - -.-...J�-> ..�,�--- -..................... Issued ------------------------------------------ ----------- ------
Date
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ger#ifirate of Taraylinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.............................ce k.......�ce. -.... .-------"-----------'----....Insmller
---------------------------------
at �,�.-(...4' -T ----,. 7................�i(J- ------J��-� .. --------------_----------------------------------------_--------
has been installed in accordance with the provisions of TITLE 5 pf The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ....-,Y�Z- �? --�............. dated ..........---.....---.........--................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SAT SF CTORY.
I
DATE......... . ..............--v.....----...----......------------------------------------------_- Inspector ---------- ----........-- ------ ......------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No...r. .-.. ... FEE. ........
Disposal Works Tonotrwtion andt
Permission is hereby granted &I------ - ------------------------•--------------------------
....... -------
to Construct ( ) or Repair (k) an Individual SewageP�,isposal Systemat No. 3...`1_._.. '..... ..-----...W<..•--- ..------ --- ----- --------••---------------•----•--•--------------------------------
Street
as shown on the application for Disposal Works Construction Permit No.-?- 1?.. Dated..........................................
----------------------------t_..-t- - ='------......--------•-------•----------.._....._._....._
Q ( I DATE............ --�----`-•-a•---•------•----------------------••-•-- \\\......11l Board of Health
FORM 36508 HOBBS h WARREN.INC..PUBLISHERS
L
No.. •- .. fa � ................
THE COMMONWEALTH OF MASSACHUSETTS
o
BOARD OF HEALTH
.............TOM----------------OF.....Barnstable
lipliration for %papal Works Tonotrairtion rrrutit
tion is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
Y
stern at: ................
•.
W Barn Q`
Location-Address or Lo o.
......... . arl��.. ....I?u�. stx •................... 1�2 Meetinghouse day, W. Barn.
................. ........--•.........................................
Owner A res
w � L Cedar St.' W. Ba�nhtable
a _ ------. ..... ------------- ---- - -----
� Installer Address
d Type of Building Size Lot_17.2,-0.0.0-......Sq. feet
Dwelling—No. of Bedrooms.........2................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( )
� Other fixtures -------------------------------------------------------------------------------
-.._ .
W Design Flow............... 50............_.. _ gallons per person per day. Total daily flow............................................gallons.
100C
WSeptic Tank—Liqu;�d'capacity........_...gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—2..................... Wid9l :...__......_....._ Total Length___ r...gW.. Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.__........._._..__. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (g) Dosing tank ( )
Alan W. Jones ? Aril 78
Percolation Test Results Performed bY.......................................................................... Date...._._.._.--- ----..
Test Pit No. 1................minutes per inch Depth of Test pit------.._........... Depth to ground water.........................
04 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................-------
Rt' -----------------------------------•-----.-•------------------- --- .-- •-••-----• --------- .
O Description of Soil.......................�-------•Loam and subsO l
.. .
_b.0• Firm fine to medium sand 6 �� l . �a
---- ------ -------- ---- -----
Z.
12 Loose coarse clean sand
-------------1 ---------------------------------------...------------------------------......----------------------------------------------------------.....----
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-•---------------------------------------------------------------------------------------------•-----------•--•------------------------•-------------------------------.-----•----------•-----•----•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue by.�e board_gLLealtJ
Slgn 7 /Y 7 9-
A Application Approved B (�- . t�
PP PP Y .�'L ,. . J
' Date
Application Disapproved for the following reasons-------------•------------------•------------•-•----.............................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued..------------...--•---------------•-•-•---------•-...
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
.............O F.......... .. ......... ......................
Tntifiratr of Tontpliatta
T IS TO CE IFY, That the Individual Sewage Disposal System constructed ( r Repaired ( )
by.. --.---- •------------ ----- ---------
I ler
at
has been installed in accordance with the provisions of T5 of The State Sanitary Code a`s�described in the
application for Disposal Works Construction Permit Nolo._..._..._�/011--------------- dated__...7-�7�__:��_...._..._.._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................•-•-------•-•--•------•-•--..........----•-•-•-••--•-••--.•.•-_. Inspector-•-- --•---.....--•---------------......---------------------.....--•-•--•---.-•--- �.
i�
No..---..-���� ..« < FEs....�..tl. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
i
Town-..... OF...Barnstable
. .............................
Appliratiou for Disposal Works Tonstrnrtion amit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
....Gedar'_ ,nd_ 1,"anle st, "l. Barn,
Location"Address
Charles ',-- . :ulton 132 TAeeting'houst3 III W. Barn.
W x Lampi °weer Cedar St. W. Ba'ft%stable
Installer ' Address
dType of Building Size Lot.I72_:00�g--------Sq. feet
"Dwelling—No. of Bedrooms.......2..................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of ersons_--___-__"_______________ Showers — Cafeteria
aOther fi tures ... .................................................................................................nc;r_.-------•--..._..----------•-----------
W Design Flow...............................V).0G._gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Wid*.................... Total Length.. #--• Total leaching area....................sq. ft.
-.
Seepage Pit No____________________ Diameter..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (X ) Dosm tank ( )
Tan W. Jones 7 Anril 7�
Percolation Test Results Performed by...........................................A.. b----------------------- Date..............:....-_ ................
a 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........................
�._,. .. ........
1;oam---ancl sub5dil----...-•-•---------•----••--•- •--•
Description of Soil--------- --- --- a""""--"--..._..•.................---- -• = _
x 0. r irm g ine co lheo�t�cri--sa I'd..."""..
U b. =1 `-----------E,o o s e---c u e Clean" " sufl a
W -----------------------------•---------------•---------------------------------------------------------------------------------....----------------•-.................................................
U Nature of Repairs or Alterations—Answer when applicable.--------------------------------------------------------------.----------_.....................
""----"------""""------""-"---""--"-""--"::-•-"---"""".....................••..........................-----------------•---..._.--•......................-----...._.__...---•--..._.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State §anitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of plian s n iss by t board of health.
D to
Application"Approved By................................•....-""•"--""--"""--"-----"-------..._.............---..........
Date
Application Disapproved for the following reasons:-------•----•""-""•-"-"-•"-""-"""-"-"----"-"-""""-""-""""-""-"•-----------------•.._._..._.........._.._._......
Date
PermitNo......................................................... Issued-.......................................................
Date
s
THE COMMONWEA)qH OF MAS!&ACkfUWTTS
+ - BOAR
- OF................Ile::.................................
.........................
,+, Tntifiratr of Tontplittnrr
T Y That theme Ind gal Aaje Di l S st i ruVP or Repaired
IS 6S
at...................`.............................................................. I... . ' ---------------------------------- ----------------------
has been installed in accordance with the provisions of TIT 17 5 of The State Sanitary Code as described in the
application for'Disposal Works Construction Permit No:........................................" dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............... ............................................................ Inspector.....................................................................................
THE COMMONWEA H OF M*S AC iU ETTS
BOAR
...........................................O F..t4e
...................:_............__......................................
No......................... ' FEE........................
y- o Ar rtio amit
us ,re --to Construct ( ) or epair ( ) an Individualage isposal System '
at No.... .. rj,*,/'fjjyp� �. 7
Sr
as shown on the application for Disposal Works Construction smut o_____________________ Datefl..____ _.:_..............................
--"-........---•-•---•--•--"-----""""-"---------"----"---"------------------------------------•---••.
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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