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HomeMy WebLinkAbout2454 MEETINGHOUSE WAY/RTE 149 - Health (2) 2454 Meetinghouse Way/Rt.149,W.Barns. t sss WEST BARNSTABLE TABLES J v TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM � NAME OF BUSINESS: �.� ft Mail To: BUSINESS LOCATION: (� Board of Health MAILING ADDRESS: Town of Barnstable P.O. Box 534 TELEPHONE NUMBER: boa _ �-- � �7 Hyannis, MA 02601 CONTACT PERSON: 7t�f G(4Z I n�f U Z-ALA'S-. _ EMERGENCY CONTACT TELEPHONE NUMBER: �a=� >-6p 7� Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totallincL at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store: Quantity/Case Quantity/Case Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes -�sf aints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, I a 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 TOWN VV N OF BARN►JTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops O unsatisfactory- 4.Manufacturers COMP (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRES Class: � 7.Miscellaneous QUANTITIES AND STORAGE (IN= indoors;OUT_outdoors) MAJ R MATERIALS 1rums Above Tanks V6 ,. - , d+� / IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) r, Diesel, Kerosene, #2 (B) Heavy Oils: , waste motor oil (C) new motor oil (C) transmission/hydraulic Synthetic Organics: XA degreasers Miscellaneous: hzo DISPOSAL/R.ECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supplyd ' ,� " O Town Sewer OP ub wy— e/tri� On-site op 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: O Holding tank: MDC O Catch basin/Dry well O On-site system 5.Waste Transporter Naine of Hauler Destination Waste Product �- YES NO 2. r/1J Person (s) Interviewed Inspect r Date r TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair BOARD OF HEALTH satisfactory 2•Printers 3.Auto Body Shops O unsatisfactory- 4.Manufacturers COMPANY r �� � 1, (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS Y A / C18S5: 7.Miscellaneous 04 QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR,MATERIALS/ Case lotsDrums Above Tanks Underground Tanks -1 IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: -PIT A waste motor oil (C)new motor oil (C) ••7 transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: . r 1�C ` Z DISPOSAL/RECLAMATION REMARKS: 1. Sanitary Sewage 2. Water Supply O Town Sewer OPublic PfOn-site forivate 3. Indoor Floor Drains YES NO—K-11 O Holding tank: MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES N0J ORDERS: O Holding tank:MDC O Catch basin/Dry well O On-site system 5. Waste Transporter Name of Hauler Destination Waste Product YES IT 1. 2. Pers (s) I Berviewed 1nspedor Date No. ASSESSORS ASSESSORS MAP NO: i _ Fps....d.......'... APPROVED THE, O//`"'��II��COM^O�N®PA E A�f h� MASSACHUSETTS�� Barnstable Conservation D TOWN OF BARNSTABLE �) Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal `System at: .t........................ ...l--q`�------ ............ .............. -...-`..----------...-----..4.............................................. L�qc ttion-:\ 9nss or t No. � O�cger A dress f4 6 Installer Address Type of Building Size Lot............................Sq. feet .., Dwelling— No. of Bedrooms......_..._3.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.-.._--__--_____-____.--.--- Showers ( ) — Cafeteria ( ) a Other fixtures ----------------------------------------------------------------------------------------------------------------------•--•-•-----•---._..__......_... W Design Flow..............................S.S__-.-gallons per person per day. Total daily flow............................ 30....0 ns. W -Septic Tank—Liquid capacity.1.0C�gallons Length__`3_,.5"._ Width... AS---- Diameter................ Depth_.. .......... x Disposal Trench--No. .................... Width.................... Total Length.......... Total leaching area....................sq. ft. 3 Seepage Pit No--------I------------ Diameter----1_a.._........ Depth below inlet___............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 .1................. N................ . ..... ........... Descri do of Soil_.. ....... U . ............................................................... W Nature of Repairs or Alterations—� swer when applicable--_�Lw� ia...1(7�x�.. -,-�1D,--011.... I 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 Compliance has been issued by the board of health. Signed ... ------- --- ..�..,.......I..... .... y Dace Application Approved B ( -'-" are Application Disapproved for the following reasons: .. ... .................................. .............. -" " --.............................--......... .............................................................................................-....................:. - _...... Dare Permit No. ..... ...... .----�� -�.... Issuedr'- ... '��J�. Date :s.-+....n.--"y..Y.,.r:.r•�.�....,_,t,f�iFY:.(dw,r...r.-e�Y,yNi�l '.•-+f w�"w.d-...-.r�-.�".�-�;yD�+tii-ti-.--�—�--�vy.ry,_..ar,::.Y�-1.. .,-�v.r.�-�-„ :r.�y.+� ^-+�.c-_ ���+�.i��, r ; NO ---•_----`''(_ � �' I 5 F�s....�� ....^"._ THE COMMONWEALTH OF MASSACHUSETTS�+ a V BOARD OF HEALTH ��`✓ �� �`7 �.�`13 TOWN OF BARNSTABLE Appliration for Diripwial Wor1w Tonitrnrtion Vantit Application is hereby made for a Permit to Construct ( ) or Repair (/an Individual Sewage Disposal System at: ... ....... 1__(49...... .... -------•---- ..................... �_..��d .� -------------- -.------- pcatioli- \ 9res5 107 or t No. . .....- 4 1_.�_0r - -.._...... Owtjer A dress W :._C`�_.. Gx... -------------------• Q•--?�cP, --? �.Q�,ta___a___._�__-_ _ G , -- Installer r AddressPQ I S feet U Type of Building Size Lot........................... q. Dwelling—No. of Bedrooms.._--_-_-_-_�-----------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- ---------••------•--•--•--•-•----•-•-•••••---............__.. W Design Flow..............................�.4___-_gallons per person per day. Total daily flow--------..--_.__-_.___.__-___.-30....gallons. W Septic Tank—Li uid capacity 9.00. alIons Len th--- -, -_ Width--- .a--_-� .. P q P � - g g � .. Diameter---------------- Depth---�-----•--- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------I.......---.- Diameter----1-;l.......... Depth below inlet._-Li............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0.4 Percolation Test Results Performed by.......................................................................... Date........................................ a ,.� Test Pit No. I................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........................ P+ Q.. •------- I> .s -•----------------})..................................... A-v ---------.... ----.... Description of Soil ` ...........6-•--- Z. t—:-.._f(A-,-n-._J.),-4*b�Uf • -- W _ _ UNature of Repairs or Alterations—'Answer when applicable-. Agreement: �----------- 3 � � e 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 Compliance has been issued by the board of health. Signed ... .. ..� & ....... ._Q..L.. �e q3:./...... ZI Proved BY ...r........ 1APPlication AP , ..................................................... "` j '.T.....Dare Application Disapproved for the following reasons: ................................ ......................... . ....................................... ..................... ....... ................................................................. ... ................. ............................................... ........._....................... -- .. ........................................ Dare Permit No. '.:.....�.�. ....... Issued ....�� '' ..�....�`� Dare r' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE NOLTWErtifirate of 11``���omplianre �_.._ THIS IS TO C RTIFY, ' h t the Individual Sewage Disposal System constructed ( ) or Repaired ( �/ ) y ..... .... ........ C?`t --_------------------------------------------------------------------.............................................. % . < -Insr.Jlcr 23' n' r has been installed in accordance with the provisions of TITLE of The State nv ironmentaI Code as des ribed,!+ the application for Disposal Works Construction Permit No. _.:�'` ..`�_ e, - dated r ' . THE ISSUANCE OF THIS CERTIFICATE SHALL NO BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � - i DATE.........._.... _........ �..— _..L. )........._....... Inspector .... --,.��---� _.......... THE COMMONWEALTH OF MASSACHUSETTS 'BOARD OF HEALTH TOWN OF BARNSTABLE No.__..._.. `._ FEE... �l Disposal IV rb Tunotrurtion "an it Permission is hereby granted-----. ...... tic' `--------------------------------- li to Construct ( ) or pair an Individual Sewage Disposal System atNo. �'�LJ ! -------------- --------------------------------•------------------...--...•---•-•......_....... street �/��yy��►► �f� as shown on the application for Disposal Works Construction Permit�o,�__ ............✓ �� - •-- Board of Health / -------- DATE.-_.._.. ---- --•-•--••---- --... f/ FORM 36508 HOBBS&WARREN.INC..PUBLISHERS AsBWjt G. Page 1 of 1 TOWN OF BARNSTABLE LOCATION 10 G'N �r4�SEWAGE # y3" `5;3 VILLAGE ASSESSf>�i;.y-�4AP d LOT �(�Z INSTALLER'S NAME & PHONE NO._ { L�� zTUT�tic SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Y '(,ylh .3 11A S-�""(si=) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER �✓ BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 9 6 ) LL �-- r L © 3a 4D (.v✓ , A http://issgl2/intranet/propdata/prebuilt.aspx?mappar=155029&seq=1 6/19/2012