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Date:
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: 9W,�� Af
BUSINESS LOCATION: 911!�7 /14�AOCO CW
MAILINGADDRESS: ,0 4e < L J,,;&, 025- 37 Mail To:
TELEPHONE NUMBER• O`6 3 3 3 2,2 Board of Health IE Town of Barnstable
CONTACTPERSON: A rs4- ¢z c�� P.O. Box 534
EMERGENCY CONTA TELEPHONE NUMBER: -U;�� ����� Hyannis, MA 02601
TYPEOFBUSINESS: A_r�AL4�,o f
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own
use? YES NO_ C
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your mailing
address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
0 Antifreeze(for gasoline or coolant systems) 0 Drain cleaners
NEW USED Cesspool cleaners
d Automatic transmission fluid �— Disinfectants
D Engine and radiator flushes �_ Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
O Motor oils ® Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Q Photochemicals (Fixers)
0 Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, ® Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal 0 Printing ink
Degreasers for driveways & garages (D Wood preservatives (creosote)
Battery acid (electrolyte) 0 Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
Car waxes and polishes Leather dyes
0 Asphalt & roofing tar Fertilizers
Paints, varnishes, stains, dyes PCB-s
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
Paint brush cleaners (including chloroform, formaldehyde,
d Floor& furniture strippers hydrochloric acid, other acids)
® Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):
_ Spot removers & cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS