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0032 BAXTER ROAD - HAZMAT
� _ _ - - f A-�,-3-6 LyLs. 2-007 i ES del E A KEEPING YOU ORGANIZED No. 10334 2-153L SUSTAINABLE YABLE FFO MIN.RECYCLED OINITIATIVE CONTENT10% CerggedSourcing POST-CONSUMER wwasfiprogram.org SFW1290 MADE IN USA GET ORGANIZED AT SMEAMOM Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS $150.00 Town of Barnstable Board of Health This is to Certify that Dip N Strip ................................................... ----------------------------------------------------------------------------- 32 Baxter Rd. Unit 2, Hyannis, MA .----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Is Hereby Granted a License For: Storing or Handling 500 gallons or more 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 y i � • Town of Barnstable l Inspectional Services BAMSTABLE 0` • • b.3St'643PNS'.tl5 OOiRWLL-F78a'nYAM1'hMWI Public Health Division 1639-20�4 .., D� C s Thomas McKean, Director t 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 ❑ CATEGORY 2.PERMIT 111 —499 Gallons: . $125.00 ❑ CATEGORY 3 PERMIT 500 or more Gallons: $150.00 El *A late charge of$10 00 will be assessed if payment is not received by July 1st. 5 gGj 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: a " 6. ADDRESS OF ESTABLISHMENT: 7• MAILING ADDRESS(IF DIFFERENT FROM ABOVE: 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: t a h L � 10. SOLEOWNER:2-1YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS A EMAIL: • SIGNATURE O T F APPLICA T DATE 6 Q:\Application Forms\Haz Mat Appli Draft Jan20l9.docx Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS $150.00 Town of Barnstable Board-of Health This is to Certify that Dip N Strip 32 Baxter Rd. Unit 2, Hyannis, MA Is Hereby Granted a License For: Storing or Handling 500 gallons or more of Hazardous Materials. ---------------------- ---------------- -------- ------------- -----------------------------------------------------------_- - ------------------ --------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2020 unless sooner suspended or revoked. PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI, M.D. 07/01/2019 JUNICHI SAWAYANAGI THOMAS A. MCKEAN, R.S.,CHO Director of Public Health r n� +.al Town of Barnstable Inspectional Services BARNSTABLE �.. �FTNE Tp�� ennwsme=•ce+re;;1. •cmm•m'uxr- 1.,.,. Public Health Division wP9C:S MtL'S.p$AYLLp•VIi LAPh„4E ias�-72nia BA.RrABLE, Thomas McKean, Director ,; 1639. a``� 200 Main Street, Hyannis, M 02601 ``A Office: 508-862-4644 Fax: 508-790-6304 h�a 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 0 CATEGORY 2 PERMIT 111 499-Gallons: $125.00 ❑ CATEGORY 3 PERMIT 500 or more Gallons: $150.00 i�Sl *A late charge of$10.00 will be assessed if payment is not received by Jules 0^c-.1h 1. ASSESSOR'S MAP AND PARCEL NO. '3 to — L'L i — ®® A 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: 6. ADDRESS OF ESTABLISHMENT: 30, 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: — ^ l 8. TELEPHONE NUMBER OF ESTABLISHMENT: e [� 9. EMAIL ADDRESS: 10. SOLEOWNER:N YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: • COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE (debj Q:Wpplication Forms\Haz Mat App Revised 09-10-18.docx -004 � 0 00 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM Mail To: NAME OF BUSINESS: ► 0� Board of Health MAILING ADDRES&S.9n MAZ R.054 Town of Barnstable TELEPHONE NUMBER: P.O. Box 534 V� Hyannis, MA 02601 CONTACT PERSON: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quan s totalling, 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: NO ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous characteristics and must be registered when stored in quantities totalling more than 50 gallons liquid volume or 25 pounds dry weight. Please put a check beside each product that you store: Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) �/ aint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, :::� :j/aint 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 f31o ,1A , o0A + 006 TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair 2. nters BOARD OF HEALTH O satisfactory 3.Auto Body Shops O unsatisfactory- 4.Manufacturers 'COMPANY -.' I r'' - _ Jr (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS ' ''r Class' 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground Tanks IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel; Kerosene, #2 (B)-_ -.... , Heavy Oils: waste motor oil (C) new motor oil (C)' transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: Y.f DISPOSAL/RECLAMATION REMARKS: r 1 Sanitary Sewage .Water Supply 7 O.Town Sewer ,QP.ublic O On-site OPrivate 3. Indoor Floor Drains YES NO O Holding tank:MDC rr' O Catch basin/Dry well O On-site system +i 4. Outdoor Surface drains:YES NO ORDERS: O Holding tank: MDC O Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product YES NO 1. 2. Person (s) Interviewed Inspector Date d / >, e ANSWER p1ME�RS� 1N��.�ER �Rp-�O : �o p,S�E Ma�� �E �� . !Ko r � R S ®� EM R P ❑ TREATS 55 GALLONS ❑ EXCEEDS E.P.A. STANDARD .'il. P ❑ EASY TO INSTALL ` 0 TREATS 55 GALLONS FOR ONLY $2.83 Finally, after years of development, a water treatment system for the small waste water generator. Treats fifty-five gallons in thirty to forty minutes. Removes paint chips and particulate solids, solubilized heavy metals and paint illy remover solvents. Costs less than $3 to treat 55 gallons of 0 water to E.P.A. standards. The system has been designed for self assembly by those with minimal hand tool skills. Tools required are: $5549500 channel lock pliers, nut driver, knife, 1/4" electric drill, screw driver, open end and alien wrenches. A video tape and F.O.B. VINCENNES, INDIANA assembly manual covers each step of installation and operation of the system. Technical assistance is available by' phone. Requires approximately 30 sq. ft. of floor space. System includes chemicals to treat four batches and two VIDEO EPA #601 water analysis test kits for analysis of treated INSTALLATION TAPE water by Kwick Kleen. A one year warranty covers system against manufacturer's defects. BE ENVIRONMENTALLY CLEAN WITH KWICK KLEEN! SPECIFICATIONS AND REQUIREMENTS SPACE REQUIREMENTS (Complete system) Height: 6' to 13' for larger unit Width: 8' Depth: 4' Weight: 385 lbs. UTILITY REQUIREMENTS Electrical: 2 15 Ampere, 100 Volt Circuits 1 — 30 Ampere, 220 Volt Circuits Air: 5 CFM at 20 PSI Vent: 2 - 3" Temperature: Minimum operation temperature 60 degrees F MOTORS 1 — 3/4 HP 110V, 1725 RPM Totally Enclosed Motor 1 — 1120 HP 110V, 1610 RPM Openface 1 — 1/8 HP 110V, 1100 RPM Openface PUMPS (OPTIONAL) 1 — 1" Self Priming Centrifugal Sump Pump LOCATION Area: Non-Hazardous Location Ventilation: 1200 to 1600 CFM Room Exhaust MAINTENANCE Due to the sensitivity of controls, periodic calibration is required. Estimated yearly maintenance; $100.00 to 200.00. ffwV'6M&'% N - ENVIRONMENTAL ENGINEERING VINCENNES, IN 47591 1-812-882-3987 i�. 9 TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair BOARD OF HEALTH 0 satisfactory 3.Auto Body Shops 0 0 unsatisfactory- 4.Manufacturers COMPANY D ,� (see"Orders") 5.Retail Stores ( 6.Fuel Suppliers ADDRESS Yd lass' 7.Miscellaneous UANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground Tanks IN OUT IN OUT IN OUT #&gallons Age . Test Fuels: Gasoline,Jet Fuel (A) Diesel Kerosene #2 B Heavy Oils: waste motor oil (C) new motor oil (C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: DISPOSAURECLAMATION REMA RKS: S: rY Sewage 8 1. Sanitary S e 2. Water Supply PP Y O Town Sewer ublic o On-site rivate f 3. Indoor Floor Drains YES NO 0 Holding tank: MDC Asks 7 t O Catch basin/Dry well a 0 On-site system 3 B 4. Outdoor Surface drains:YES NO ORDERS: 0 Holding tank: MDC O Catch basin/Dry well 0 On-site system 5.Waste Transporter Name of Hauler Destination Waste Product l. � � �„�• YES NO 2. og VL-6 erson W Inte iewed Inspector Date lr TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair 2.Printers BOARD OF HEALTH 0 satisfactory 3.Auto Body Shops o o tQ{� Q unsatisfactory- 4.Manufacturers COMPANY 11 1/ P n���/f o (see"Orders") 5.Retail Stores tt ��..� 1 6.Fuel Suppliers ADDRESS +-tom A o, 1 y�?�jU l ,(;lass; 7.Miscellaneous Sl QUANTITIES AND STORAGE (IN= indoors; OUT-outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground Tanks IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil (C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: DISPOSAURECI AMATION REMARKS: 1. Sanitary Sewage 2. Water Supply O Town Sewer ��Public Q On-site QPrivate 3. Indoor Floor Drains YES—NO- 0 -~ Holding tank:MDC - � Q Catch basin/Dry well C /°k/V G4 6--fl O On-site system 7-')ji l4 � V r - 4. Outdoor Surface drains:YES NO ORDERS: Q Holding tank:MDC ' O Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product YES NO 2. r Person (s) Interviewed Inspector Date Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS $150.00 Town of Barnstable Board of Health This is to Certify that Dip N Strip 32 Baxter Rd. Unit 2, Hyannis, MA Is Hereby Granted a License For: Storing or Handling 500 gallons or more of Hazardous Materials. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2019 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 .ice'-`i.il^xQa,�s_��:< 1 k '�Oegu'Aatoryw of BVnstable Services THE Richard V. Scali, Director , OF � • u�u�{c Public Health Division BARNSTABLE • s r aanNSTaetE.r&rtEnVluF.miUR•4YM4i15 A.MBL& = Thomas McKean, DirectorMAS& i° 9-'o;"� prE1 �a -- - 200 Main-Street;Hyasuus�MA 02G01--- -- - -- - �.a } Office: 508-862-4644 Fax: 508-790-6304 Cn APPLICATION FO PERMIT TO STORE AND/OR UTILIZE �°R HAZARDOUS MATERIALS t IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, Ewa 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 ❑ CATEGORY 3 PERMIT 500 or more Gallons: $150.00 . VS , t *A late charge of$10.00 will be assessed if payment is not received by July 1st. -PC-f- 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 ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF • GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: `I 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: e �C 4�°�•S �d n �� 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE:: 8. TELEPHONE NUMBER OF ESTABLISHMENT: - 9. EMAIL ADDRESS: ,�Q�c�c�S(�-�� 9 J►ny. c-uv A 10. SOLEOWNER: YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: • SIGNATURE OF APPLICANT DATE all I f Q.Application Forms\I-IAZMAT APP 2017 REVISED.docx °p IKE A Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 • BA C LE,MASS. ' \ MAC 200 Main Street• Hyannis, MA 02601 1639. �prFDMP+�`0� TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: Dip 1 Date: 2 7 Location/Mailing Address: 32 6xx e-( K� 2 ch Contact Name/Phone: ;6)-e_X 6oWye Sod; - "7'1 J 70 y zf Inventory Total Amount: A�-J 4 SDS: .f,5 License#: Tier II : Labeling: OK. Spill Plan: A'° 04t Oil/Water Separator: Floor Drains: K,o Emergency Numbers: e- Storage Areas/Tanks: v Emergency/Containment Equipment:H-1c, Av�Waste Generator ID: 150�b,"1 `I Waste Product: Pay► Date&Amount of Last Shi ment/Fre uenc : 3 Licensed Waste Hauler&Destination: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALSI`.Q' vo NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, OAe 61-C�,�y storage and disposal of 111 gallons or more requires a license from the Public Health Division. 4-o I K evl'�'o��/ 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 7 Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's 7 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: A v ►1, 4 k2xl'sw &A �V�11, Inspector:A I. Facility Representative: A cyrz—z,— WHITE COPY- HEALTH DEPARTMENT/CANARY COPY-BUSINESS • • 41k, Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS $150.00 Town of Barnstable Board of Health 9� s This is to Certify that Dip N Strip 32 Baxter Rd. Unit 2, Hyannis, MA Is Hereby Granted a License For: Storing or Handling 500 gallons or more of Hazardous Materials. ------------------------------------------------------------------------------------------------------------------------------------------------------------------ This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2017 - unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 07/01/2016 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health `• Town of Barnstable ►�,,, Regulatory Services ti Richard V. Scali, Director ` BAMST °"�' "B Public Health Division 1639 �0� c.. ` wvraa r�uFmvs Bums 1639-2014 Thomas McKean,Director. .200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 �1�. Fax: 508-790W04 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 1 st-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 Julyp 1st. ASSESSORS MAP AND PARCEL NO. DATE FULL NAME OF APPLICANT: $ ' ' ? _4 1�� C • �`k` 9��C"Vigz. NAME OF ESTABLISHMENT: ADDRESS OF ESTABLISHMENT: , - i'�9`; 'j►^�! l MAILING ADDRESS(IF DIFFERENT): TELEPHONE NUMBER OF ESTABLISHMENT: EMAIL ADDRESS: ` E1. C' r'1'��c a 6�•� 1� SOLE OWNER: P""YES_NO IF NO,NAME OF PARTNER: FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK IF PREPARED BY OUTSIDE PARTY: SIG OF APPLICANT Name: ,k Company Address f Telephone#: Email: QAApphcation Forms\HAZZAPP Revl6.docx Page 1 of 2 °p IKE*off Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 ' BABNSPABLE. ' 200 Main Street• Hyannis, MA 02601 MARS- A TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: - ' - Date: z Z I Location/Mailin Address: 3Z Je,0JX mylyll-,� Contact Name/Phone: D - -7`/S-?O -Inventory Tota Amount: ^' 10 O MSDS: 7 e,5 License#: Tier II : WR Labeling: i9c Spill Plan: O Oil/WaterSeparator: Floor Drains: D Emergency Numbers:Y2 Storage Areas/Tanks: N;^y I K I&k iz W45+-6 S vl gL-cg, . 2 % 5A`V- a-C4e.- , 5 5 �Ao`I C-►�.a� Emergency/Containment Equipment: `5 << "4- 5 4 -e v^ - oowA.s Q%A S Waste Generator ID: M\J 000 'I bqi4 Waste Product: W6 +-& - %%A r_-1 50(,QS Date&Amount of Last Shipment/Frequ v: J(9 1 2-7 1 f Y. Licensed Waste Hauler&Destination: �« ofc� P a•r a� 7 6 ,1 25o.nce� Other Waste Disposal Methods: , LIST OF TOXIC AND HAZARDOUS MATERIALS ( O V�\od 6k&Ae-, "A- Slv te- 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 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 VZ 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/REQOMMENATIONS: vt o' I K043 b A \ c. Ll tX N Inspector: Facility Representative: WHITE COPY- HEALTH DEPARTMENT/CANARY COPY-BUSINESS IKE A Town of Barnstable Office:508-862-4644 u Fax:508-790-6304 . Public Health Division BARMA Aq E. ' 200 Main Street• Hyannis, MA 02601 S 4 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: . c5"c_kip Date: Location/Mailing Address: 37- R--yxAe,! P, i+7 1,1 v►vil P S Contact Name/Phone: XeY, .Anw,JVP-( <03 _-7-7 S',-70(4 Inventory Total, Amount: A- "l y ( (,I MSDS: 7 e 5 License#: j Tier II : f� _ Labelina f na ' Spill Plan: Oil/WaterSeparator:, Dr Floor Drains: t? Emergency�Numbers: Ye Storage Areas%Tanks:(,9 t oJoA4 I vt �Au,-1 wu 5{, Emergency/Containment Equipment:"-67 A, V 4/>V h IA e, �` t� b cP�S ��� .���IS Waste Generator ID: M� 4'�`7't<76 N t4 n Waste Product:' %6K6-t-R ',K4/4,,ewe--r Date&Amount of Last Shipment/Frequency: f Licensed Waste Hauler&Destination: ��� (�a .�� ira-��1� e scarce` �4c Other Waste Disposal Methods: ' a LIST OF TOXIC AND HAZARDOUS MATERIALS 1�0 Mu 10l OA A 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 V/ Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including'-brake fluid) t ,;' Windshield wash j 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 I Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers 111V 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'tetrachioride) (including bleach) .;' Any other products with "poison labels" # (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION RECOMMENDATIONS: -A 0 VA I� l J4i_ t 41Vt0l f 1 t? t3� ok c c. �_e I ! o �5Sv�5 o< c� .c �1My -e r t�o�cS Q� -4-14 /, , 'o Inspector:- R rl 6\J-e w Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY- BUSINESS r� Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that Dip & Strip 32 Baxter Rd. Unit 2, Hyannis, 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 t4r Town of Barnstable °FtHE r Regulatory Services • °� Richard V. Scali, Director r r E" MASS. ' Public Health Division 9•9qj i6g `0� RFD A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 fd Fax: 508-790-6304 Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO.� �� �-Ia 1 DATE / 7Ll T APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN I I I GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT NAME OF ESTABLISHMENT ADDRESS OF ESTABLISHMENT TELEPHONE NUMBER SOLE OWNER: C� YES 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 RESTRICTIONS: HOME ADDRESS � �r +6 HOME TELEPHONE# s C°,cache\Temporary Intemet FilemOLKDMAZAPP ReQ015.DOC 3 , ` Gam, A3 °Ft►�ion Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 RnRMASS. D` 200 Main Street• Hyannis, MA 02601 2639. TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: ff i Date: Location/Mailing Address: Z eP,.Q QV%,+z- a"r, 6 Contact Name/Phone: Al e-x Inventory Total Amount: 1-100 q 1-1 MSDS: e5 License#: �y 1 Tier II : tJ o Labeling; �xl CQv-_5 1w wait(w&-Spill Plan: Oil/WaterSeparator: N�� Floor Drains: ►J o Emergency Numbers: Storage Areas/Tanks: ou 4kl A6)6 iu,Cvyt�ra�w •nk�oo,�. -S al �2r��.� �K� k� Emergency/Containment Equipment: Waste Generator ID: o <1 Waste Product: A%�tk-re�at wq e Date&Amount of Last Shipment/Frequency: cl 111P 113 f ,de- �o y Licensed Waste Hauler&Destination:r("ol C Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS I o ,na y I u 1 c\AkvJ�b ,•ti %v.v,eW-No.< o r NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous miterial use,storage and 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 J 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: Inspector: Facility Representativ . WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: / / /y / 0 TOWN OF BARNSTABLE 10 TOXIC AND HAZARDOUS MATERIALS REG! N FORM NAME OF BUSINESS: 1 L N 6+n BUSINESS LOCATION: 6 INVENTORY MAILING ADDRESS: Say* e TOTAL AMOUNT: TELEPHONE NUMBER: .S >5 - 7'75--70qy ^� l700 Z/�oNS CONTACT PERSON: 40-x 0U>Ve,- EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: )eS-�0 Atc..���f1, INFORMATION / RECOMMENDATIONS: �] lge-lab-o all cm�-�1+�-rs Of s strict: ` Fire District: l a 'l5 ,tee- r z� 4acl:e s�ara 4Vt GL fim 1 �,s a v►n I!1Q Ntli.�' PC Oke,16✓ y►o l ov►fit! v f�Gl , 'S� '�'eQg, l�-i hQ� G��am�-f- Waste T men. • NIV,5-9>8-77S7D4y Last shipment of hazardous waste: Name of Hauler: -r(WA01d 6VfAIf, -✓1G• Destination:A,4Kf tq,95Axee- I- , y Waste Product: Licensed 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. Lees+ ,ktf 8.0P%- LIST O'F TOXIC AND HAZARDOUS MATERIALS - A)v yt,v� Iw The Board of Health and the Public Health Division have determined that the fdllowing products dxhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Obse ed / 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, Laic uer thinners (including carbon tetrachloride) ly NEW �`UUSED 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 -i So A0 �J�1v �a� �� �� �fr�*f6, I J� l• Laundry soil &stain removers (including bleach) .�-o � meA-tkwl, �ebexx— t&Kk- Spot removers &cleaning fluids (dry cleaners) Oxuai G q G�D� a►2/2- CGU57'L �n 2 '�a�� Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials I Town of Barnstable DIKE r, Regulatory Services Thomas F. Geiler,Director s Public Health Division BARNSTABLE, Thomas McKean,Director v MASS.1639. $ 200 Main Street, Hyannis, MA 02601 Phone: 508-862-4644 Email: health@town.barnstable.ma.us Fax: 508-790-6304 Office Hours: M-F 8:00—4:30 March 5,2008 Mr.Dudley Scott, Owner RE: Toxic and Hazardous Materials Dip N' Strip On-Site Inventory and Inspection, 32 Baxter Road, Unit#2 Dip N' Strip, Hyannis, MA 02601 32 Baxter Road,Unit#2, Hyannis Dear Mr. Scott: On February 28,2008,a Toxic and Hazardous Materials On-Site Inventory and Inspection of the above referenced site was conducted by the Public Health Division(PHD). An On-Site Inventory and Inspection is a review of the sites storage,transport,utilization and/or disposal of toxic and hazardous materials as it relates to the Town of Barnstable Ordinance,Chapter 108: Hazardous Materials. This Ordinance was adopted to protect the public health and welfare,especially as it pertains to the public drinking water supply. , The following is a description of the results of the Inventory(enclosed)and Inspection. MATERIALS INVENTORY AMOUNT AND PURPOSE: The Inventory of this site indicates the use or storage of approximately one-thousand,one-hundred and thirty-four(1,134)gallons of toxic and hazardous material. This material is used in the repair,stripping and coating of furniture performed at this site.Please be aware that the Town of Barnstable has determined that a minimum of one-hundred and eleven(111)gallons of toxic and hazardous materials requires an annual license. GENERAL STORAGE AREAS AND CONDITIONS: • The Production Room,houses a paint spray booth,and flammables cabinet. • The Chemical Storage Room,to the rear of the Production Room,houses the majority of paints, lacquers and stains. • The Stripping Room consists of hazardous waste storage, a solvent tank,caustic soda tank and oxalic acid tank. This room is reportedly explosion proof, is bermed and vented. SAFETY AND DOCUMENTATION: The required Material Safety Data Sheets were available and in a binder in the office. A Contingency Plan was not available nor was a Spill Kit. Manifest sheets for the proper transport of hazardous materials were also provided upon request. -2- Fire extinguishers were available and their inspection up to date. A License for Storing or Handling 111 Gallons or More of Hazardous Materials was posted on the Chemical Storage Room door. SITE FACILITIES: The facility floor is constructed of concrete,no floor drains were observed at the facility. The site building is served by town sewer and water. Any deficiencies which were discovered in the course of this inspection with regards to the Hazardous Materials Ordinance are described below. RECOMMENDED CORRECTIVE ACTIONS TO BE TAKEN: The Chemical Storage Room should be labeled at flammable. A Contingency Plan, with a list of emergency contacts,actions to be taken in the event of a spill,and the location of a Spill Kit(absorbent materials) is to be made available and posted near the telephone. The PHD appreciates your cooperation and your intent to maintain compliance with the Hazardous Materials Ordinance. Please contact me at the above telephone number should you have any questions or comments regarding the Inspection of your site. Very truly yours, Cynthia A.Martin Hazardous Materials Specialist All orders to correct violations of Chapter 108 of the Town of Barnstable Ordinance: Hazardous Materials. shall be completed upon receipt of this letter Thomas A. McKean,RS,CHO Director of Public Health Enclosure: Toxic and Hazardous Materials On-Site Inventory tl Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS $150.00 Town of Barnstable Board of Health , This is to Certify that Dip N Strip 32 Baxter Rd. Unit 2, Hyannis, MA Is Hereby Granted a License Y For: Storing or Handling 500 gallons or more of Hazardous Materials. --------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- ------------------------------------------------------------------ This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2018 unless sooner suspended or revoked. ------------------------ --------------- Q 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 r< i TRown of Binstable eg atory ervices Richard V. Scali,Director Wo„ Public Health Division BARNSTABLE f.. BANxSfMLE.yFxfEi:VILLE.COILII•HYui:15 a (= Bn AMR, Thomas McKean,Director 1639 1639 2LLE=IT.51 P4cry5i<nc -2014 °rev 39,E s`� 200 Main Street,Hyannis,MA 02601 �g Office: 508-862-4644 ov/ F^RO/46 Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 1P08, 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 ElCATEGORY 2 PERMIT 111 —499 Gallons: $125.00 ❑ CATEGORY 3 PERMIT 500 or more Gallons: $150.00 VS.j *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 • ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUTANTITIES(25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: (� ( �-- 5. NAME OF ESTABLISHMENT: 4 ` Z— �- 6. ADDRESS OF ESTABLISHMENT: 322, CA),4c.( 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: S. TELEPHONE NUMBER OF ESTABLISHMENT: _ —S� C15 - 9. EMAIL ADDRESS: Q �-�I: S�� toy L 10. SOLEOWNER: �1,4S NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT . DATE W111 Q:\Application Forms\HAZMAT APP 2017 REVISE ocx Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that Dip & Strip 32 Baxter Rd. Unit 2, Hyannis, 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 °FINE ra,, Regulatory Services ti Richard V. Scali, Director BARN B Public Health Division i°rEo nna'�" 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. 5/0° 1V 004 DATE 13 1 I, APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT NAME OF ESTABLISHMENT Yl ADDRESS OF ESTABLISHMENT 30 TELEPHONE NUMBER SOLE OWNER:✓ YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: y i IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER CLERK or j SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS HOME TELEPHONE# Q:iApplication Forms\HAZAPP.DOC Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS $100.00 Town of Barnstable Board of Health This is to Certify that Dip & Strip 32 Baxter Rd. Unit 2, Hyannis,MA 02601 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. 6/30/2013 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health fi 1 Town of Barnstable of, Regulatory Serv1cEs Thomas F. Gefler,Dirzidu i io-n Pilbb.c Health D1� y MARS. �^ Thaws MCKEaIIj DirEctD3' 2D0 amain Strut, Hya�s, AAA 02601 Fes: 5o&790-6304 OEcE: 508-S62-4644 App1ica1�ion Fes: $100.D0 ASSESSORS ASAP AND PARCEL NO, DATE APPI�I�ArIrl�t t F�f�PE 'SIT T® STORE AND LnR TTTILIT7 SORE THA-�i 111 G�LLaNS Off+' RAIAd�DQUS MATU T ALS SILL NAME OF APPLICANT 7D v NANa OF ESTABY ISEMzNT Q ADDRESS OF ESTAMLEEN.INN T^ -- TELEPHONE S CLE O'4vN:KR: V YES NO I H APPLICANT IS A PARTN ,I+-ULL NAME AND HOlYSE ADDRESS OF ALL PARTN7-BS: o kH b. C IF APPLICANT IS A CORPORATION: FEDERAT IDENTICATION 3`I O. STATE OF I1 TCORPORAnON N FITLL N-A-Ml AND EONa ADDRESS OF: , PF>ESM + qaEAECRIR CLERK SI OF AYPI,.ICA1'iT kA i �STRICTIo1 TS: EOAIE ADDBEss HoNa T=EC)NE # �® i H=docNq/q Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS $100.00 Town of Barnstable - Board of Health This is to Certify that Dip & Strip 32 Baxter Rd. Unit 2, Hyannis,MA 02601 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 6/30/2013 unless sooner suspended or revoked. ----------------- ------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF, D.M.D. 6/30/2012 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health I .61 Fu Town of Barnstable 0p1HE 79 Regulatory Services Thomas F. Geiler,Director BMASS.AMSTAMEX, Public Health Division S 1639.nnA�' Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 5W790-6304 Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO3 I 'OAATE APPLICATION FOR PERMIT TQSTORE AND/OR UTILIZE MORE THAN t 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT 0 to S p'1 NAME OF ESTABLISHMENT �r►P ADDRESS OF ESTABLISHMENT 1 A- k-)A` Z TELEPHONE NUMBER �Tp op SOLE OWNER YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL , PARTNERS: _ # rn IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER CLERK . IGNATURE O PLICANT i RESTRICTIONS: HOME ADDRESS At o r^ HOME TELEPHONE# (1911f �(a i Haz.doc!wp/q Number Fee 301 THE COMMONWEALTH OF MASSACHUSETTS $loo.00 Town of Barnstable Board of Health This is to Certify that Cape Cod Commercial Linen Service, Inc. 32 Baxter Road, Hyannis,MA 02601 Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. ----------------------------------------------------------------------------------------------------------------------------------------- -------------------------- N ------------------------------------------------------------------------------------------------------------------------------------------------------------------ 0 This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 6/30/2012 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 6/30/2011 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health Town of Barnstable A 100.0o THE, Regulatory Services ti Thomas F. Geiler,Director MASS. ' Public Health Division 'OrEn 59. 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. �3 ly 006 DATE �" c'`�I 2.C� tj APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN III GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT I ar—e-c) �&A??►Tv-u �Ptfit� NAME OF ESTABLISHMENT CO (cw Pi ev o l tA-c-• ADDRESS OF ESTABLISHMENT kA7 TELEPHONE NUMBER -1 I _5 gy, SOLE OWNER:_JYES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. Qk4-334&45C STATE OF INCORPORATION NV FULL NAME AND HOME ADDRESS OF: PRESIDENT 1L\e L+rek., a 5 Sv►0b Uct)lam, V0 P v '2 D WA'1 ct444-u2-6S 5 TREASURER CLERK SIGNAT OF APPLICANT RESTRICTIONS: HOME ADDRESS sclwf HOME TELEPHONE# 5� ?_X 1 to�Q Haz.doc/wp/q r Cape Cod Commercial Linen Service, Inc. Main Plant: 485 West Main Street, Hyannis, MA 02601 Seasonal Plant: 32 Baxter Road, Hyannis, MA 02601 Customer Service: 508-771-5033 HAZARD COMMUNICATION PROGRAM Revised April 4, 2011 Cape Cod Commercial Linen Service, Inc. HAZARD COMMUNICATION PROGRAM I INTRODUCTION II� II HAZARD DETERMINATION PROCEDURES III LIST OF HAZARDOUS MATERIALS IV PROCEDURES A. LABELS AND OTHER FORMS OF WARNING B. INFORMING CONTRACTORS ABOUT HAZARDS C. CHEMICAL SPILLS AND ACCIDENTS D. CHEMICAL HANDLING, STORAGE,AND DISPOSAL V PERSONAL PROTECTIVE EQUIPMENT VI TRAINING VII APPENDIX APPENDIX A SAFETY COMMITTEE MEMBERS APPENDIX B MSDS SHEETS APPENDIX C EMERGENCY PHONE NUMBERS I INTRODUCTION Cape Cod Commercial Linen Service, Inc.(CCCLS) seeks to protect its employees from all unsafe exposures to hazardous chemicals known to be present in the workplace. Employees have a responsibility to learn and follow the procedures we have established to assure basic awareness of hazards and safe use of materials in our workplace. To ensure that all avenues are addressed,the following written hazard communication program has been established for all departments at CCCLS. These plans are to be reviewed by the Safety Committee at least every 12 months and updated as necessary to reflect significant changes in the status of our program. A list of the Safety Committee members is contained in Appendix A. The Safety Committee is responsible for seeing that all aspects of the program are carried out. A copy of this Program and the applicable OSHA standards are available in the office of Paul Marcey for review. II HAZARD DETERMINATION PROCEDURES In accordance with the OSHA standard,we will rely upon the chemical manufacturer to identify and evaluate the various hazards of the chemicals they supply to us. The Safety Committee will rely upon information provided on the Material Safety Data Sheet(MSDS). The MSDS is to identify all of the chemical characteristics as required by the OSHA standard. The Safety Committee will insure that MSDS's are readily accessible and that supervisors know their location. A. Respective Department Heads should see that each MSDS sheet is reviewed when received to see that it contains the following information: * Identities used on labels * Chemical and common(generic)names * Physical and chemical characteristics * Physical hazards * Health hazards(signs & symptoms of exposure,medical conditions aggravated by exposure) * Primary routes of entry * Air exposure limits * Carcinogenicity * Emergency and first aid procedures * Date of preparation of MSDS * Name, address and phone number of MSDS preparer or distributor * Any generally applicable precautions for safe handling and use that are known to the chemical manufacturer or employer preparing the MSDS, including appropriate hygienic practices, protective measures during repair and maintenance of contaminated equipment,and procedures for clean-up of spills and leaks. * Any generally applicable control measures which are know to the chemical manufacturer, or employer preparing the MSDS, such as appropriate engineering controls, work practices, or personal protective equipment. * The OHSA permissible exposure limit,ACGIH Threshold Limit Value, and any other exposure limit used or recommended by the chemical manufacturer or employer preparing the MSDS. * Whether the hazardous chemical is listed in the National Toxicology Program Annual Report on Carcinogens(latest edition) or has been found to be a potential carcinogen in the International Agency on Cancer Monographs or by OSHA. B. The Safety Committee will write to the supplier for any missing information. If the supplier does not respond within 30 days the purchaser will be notified to fmd a new supplier or the Safety Committee will file a complaint with the local OSHA Area Office. C. The Safety Committee will coordinate necessary monitoring for any chemical in the workplace which is questionable or required by law. Monitoring will be conducted in one of the following manners: (1) in-house using Wittenberg University equipment and personnel or(2)by an independent consulting firm. III LIST OF HAZARDOUS CHEMICALS A complete list of MSDS's for all chemicals used within CCCLS will be kept in the office of Paul Marcey. Further information such as the physical&chemical hazards of the chemicals, Detection methods and protective measures for each chemical can be obtained by reviewing the MSDS. Employees are entitled to a copy of the MSDS if they so request. The list of all hazardous chemicals shall be subjected to cross-reference to the MSDS for each listed chemical. IV PROCEDURES FOR LABELING AND OTHER METHODS OF COMMUNICATION A. Labels and Other Forms of Warning. All containers in the workplace are to be labeled. The purpose of labeling each container is to properly identify the contents of the container so that the employee is warned as to what type of hazard(if any)the contents of the container present. a. Since chemical manufacturers are required to label their containers, CCCLS will use these labels as our primary means of labeling. Such chemical manufacturers are required to label their containers to meet OSHA standards. b. Chemicals removed from the original bottles will be identified by a label which shall contain the name of the chemical,the date on which the label was prepared, and the initials of the person preparing the label. Solutions will be labeled with the identity of the solvent,the concentration of each of the solutes,the date on which the solution was prepared, and the initials of the person who prepared the solution. For those chemicals and solutions for which a significant fire, explosion,health, or carcinogenicity hazard exists,the label shall identify the hazard and the severity of the hazard. For each type of hazard with a solution,the hazard severity information indicated on the label shall be, for that hazard,the most severe hazard indicated on the MSDS for any of the constituents of the solution. The MSDS will be used in each case where a label is lost or illegible. c. The Safety Committee or their designee within the respective departments will ensure that all containers of chemicals in the departments are correctly labeled. Any container which does not have this information may be returned to the supplier, at the supplier's expense. d. Each Department Head has the overall responsibility of ensuring that all containers of chemicals used in his or her department are correctly labeled. e. Labels are not to be removed from any container, or defaced in any manner. f. Empty containers are not to be re-used to store other materials unless the container has been cleaned, the old label removed, and a new label affixed in its place prior to its re-use. B. Informing Contractors about Hazards. To assist in evaluating potential exposures and to ensure that a contractor's employees are provided with information regarding potential hazards,prior to any contractor entering the work site the Director of Physical Plant, in consultation with the appropriate department head, will notify the contractor of any potential hazards relating to chemicals. The Safety Committee is a resource for the Director of Physical Plant to use to assist in identifying any potential hazards in the work site. C. Chemical Spills and Accidents. a. Should a hazardous material spill or accident occur, immediate attention is required by the person causing the spill to minimize the spread of the spilled material. It is then the responsibility of the person causing the spill to report the spill to the department supervisor. Except for the most minor spills,the department supervisor will arrange for the cleanup of the spilled material. Outside help will be called in to clean up the spill when the extent of the spill or the material involved in the spill are such that inside help is not capable of handling the situation. b. In the event of a hazardous material emergency outside a building, outside help may be called in to help clean up the spill when the extent of the spill or the material involved in the spill are such that inside help is not capable of handling the situation c. After the emergency, a Security Department "Incident Report" will be completed by the Security Department(sample "Incident Report" is shown in Appendix E). All accidents or near accidents will be carefully analyzed by the Safety Committee and the recommendations arising from the analysis will be distributed to all who might benefit from the information. Also, as a follow up to any safety related Incident Reports, a written recommendation will be sent to the Director of Security and a copy filed with the Incident Report for a permanent record. d. In the event of chemical exposure to the eyes, employee will be directed immediately to the "'Emergency Eye Wash Station"located next to the tying machine. The employee must flood the effected area for 15 minutes until the chemical is washed out. i e. In the event of chemical exposure to the body, employee will be directed immediately to the wash room, either men s or women s, and wash the effected area for 15 minutes until the chemical is washed out. D. Chemical Handling, Storage and Disposal. Materials will be stored, insofar as is practicable, in their original containers. Bottles of chemicals should be placed on the storage shelves in such a way as to minimize the danger of bottles falling off the shelf. Chemicals will be stored on the shelves by chemical property. Highly toxic materials will be stored separately from other chemicals in a room which is locked when not in use. Flammable materials will be stored separately from other chemicals in special cabinets. All chemicals will be examined at least annually to determine the need for replacement and the integrity of the container and label. The proper disposal of hazardous material wastes is necessary to protect people,plants, and animals from harm that could be caused by the improper and careless disposal of these wastes. V PERSONAL PROTECTIVE EQUIPMENT Most personal protective equipment is provided by CCCLS to employees when and where necessary. It is the responsibility of each employee to be certain that the appropriate equipment is worn as necessary. The assessment of any hazards associated with exposure to hazardous chemicals which require the wearing of personal protective equipment is the responsibility of CCCLS. It is the responsibility of each employee to wear personal protective equipment as provided by CCCLS or as required by CCCLS. Eye Protection: Appropriate eye protection is provided to be worn by all persons,when chemicals are handled. For specific regulations see a copy of the "Wittenberg University Eye Protection Policy" attached to the Chemical Hygiene Plan. Hand Protection: Appropriate gloves are provided to be worn when the potential for contact with toxic materials exists. Inspect the gloves before each use. : Use appropriate dust masks when air containment concentrations are excessive. Inspect the dust masks before use. Miscellaneous: Use any other protective and emergency apparel and equipment appropriate. VI TRAINING CCCLS will provide employees with information and training on hazardous chemicals in their work area at the time of employment and whenever a new hazard is introduced into their work area. Annual refresher training will also be given. The Safety Committee will make available to each new employee a copy of the MSDS pamphlet(Appendix D). Our training is to be an opportunity to explain to employees not only the hazards of the chemicals in their work area, but also how to use the information provided in our Hazard Communication Program. This training will be accomplished by the department supervisor in an on-the-job basis. Training will include an opportunity for employees to ask questions to ensure that they understand the information presented to them. Specifically,the.training will include the following: ;a. The requirements of the applicable OSHA standard 29 CFR 1910.1200. b. The operations in their work area where hazardous materials are present. c. Methods and observations that may be used to detect the presence or release of a hazardous chemical in the work area(visual appearance, odor,monitoring, etc.). d. The physical and health hazards of the chemicals in the work area. e. The measures employees can take to protect themselves from these hazards, including specific procedures CCCLS has implemented to protect the employees from exposure such as appropriate work practices, emergency procedures, and personal protective equipment to be used. f. The details of this Hazard Communication Program;the location and availability of the written program; an explanation of the labeling system and the MSDS; and how the employees can obtain and use the information. g. The personal protective equipment required for the employees specific job (if any). APPENDIX A SAFETY COMMITTEE MEMBERS APPENDIX B MSDS SHEETS APPENDIX C EMERGENCY PHONE NUMBERS APPENDIX A Safety Committee Members Jeffrey Ehart,President/Owner Max Cesard, General Manager,West Main Street Manager Paul Greenwood,Baxter Road Manager APPENDIX B MSDS SHEETS MSDS Sheets are available for review and are located in the office of Max Cesard and Paul Greenwood or the designated manager at the appropriate plant. APPENDIX C EMERGENCY PHONE NUMBERS Police 911 Fire 911 i Rescue 911 Poison Control 1-800-222-1222 Chemical Emergency Assistance 1-800-424-9300 MassDEP 508-946-2785 Triumvirate Environmental 800-966-9282 Barnstable Health Dept. 508-862-4644 CCCLS Contacts West Main Street Plant Jeffrey Ehart, Owner 508-428-1639(H), 508-776-3066(CELL) Max Cesard, Manager 774-360-7977 (CELL) Ricardo Ferla,Asst. Manager 508-280-8276 (CELL) Baxter Road Plant Jeffrey Ehart, Owner 508-428-1639(H), 508-776-3066(CELL) Paul Greenwood,Manager Baxter Road 508-280-2388 (CELL) Alex Fernandez,Asst. Manager Baxter 508-360-9943 (CELL) Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS $1oo.00 Town of Barnstable. Board of Health This is to Certify that Dip & Strip 32 Baxter Rd. Unit 2, Hyannis,MA 02601 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 6/30/2012 unless sooner suspended or revoked. --------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 6/30/2011 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health r� I Town of Barnstable ( ►yy( - 5� FfHE rq�, Regulatory Services I B M �O Thomas F. Geiler, Director 4 i i 4 i PMAS Ix. " Public Health Division �E039. � 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 I APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT V� NAME OF ESTABLISHMENT i ADDRESS OF ESTABLISHMENT vim" + � p TELEPHONE NUMBER <O �`ICJ ® 4!11 SOLE OWNER: YES NO , G C)i IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS O ALL 'ry PARTNERS: tV a N g 9 • FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION 1 FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER CLERK ' SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS HOME TELEPHONE# 3 (, - Haz.doc/wp/q �'� MAIL-IN REQUESTS Please mail the completed application form to the address below. In addition, please include the required fee amount. Make check payable to: Town of Barnstable. 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. In addition, you must mail the required fee amount (see fees at bottom of this page). Please make the check payable to: Town of Barnstable. The check must be mailed to the address listed above. For further assistance on any item above, call (508) 862-4644 i ti Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS $1oo.00 Town of Barnstable Board of'Health This is to Certify that Dip & Strip 32 Baxter Rd. Unit 2, Hyannis,MA 02601 Is Hereby Granted a.License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 6/30/2011 unless sooner suspended or revoked. ----------------- WAYNE MILLER, M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. _ 6/30/2010. JUNICHI SAWAYANAGI THO,MA$.A..MCKEAN,R.S.,CHO w>- --r- - Director of Public Health Town of Barnstable �oFSHe�Owti Regulatory Services P Thomas F. Geiler, Director BA LE,MASS. : Public Health Division MASS. a 9�O 1639. 0M A 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 41;/ IqI16 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT 1. NAME OF ESTABLISHMENT 1 ADDRESS OF ESTABLISHMENT &�O\GQ'J � � (� A � I • L TELEPHONE NUMBER �� "'�X-7 b V / SOLE OWNER: YES 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 SICN RE OF APPLICANT:/ RESTRICTIONS: HOME ADDRESS n C61-A �� �� t10 1l 4140 d/fq HOME TELEPHONE # Haz.dochk p/q s O Number Fee r 141 THE COMMONWEALTH OF MASSACHUSETTS $100.00 Town of Barnstable Board of Health This is to Certify that Dip & Strip 32 Baxter Rd. Unit 2, Hyannis,MA 02601 Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires June 30, 2009 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 07�0� �$ JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health 4 Town of Barnstable Barnstable 'THE r Regulatory Services Department o� ;aicaCftv Public Health Division �.Y BARNSCABLE, � 200 Main Street,Hyannis MA 02601 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 MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT NAME OF ESTABLISHMENT ADDRESS OF ESTABLISHMENT TELEPHONE NUMZE OK �7S SOLE OWNER: YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: N � ' ` IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NOS -r F3 D STATE OF INCORPORATION v r*i FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER CLERK SI ATU APPLICAN/T l� RESTRICTIONS: HOME ADDRESS HOME TELEPHONE# dc— S 6 - Q:\Hazmat\Haz Mat Application2008.DOC Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS $1oo.00 Town of Barnstable Board. of Health This is to Certify that Dip & Strip 32 Baxter Rd. Unit 2, MA 02601 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 June 30, 2008 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN SUMNER KAUFMAN,M.S.P.H. 7/9/2007 PAUL J. CANNIFF,D.M.D. THOMAS A.MCKEAN,R.S.,CHO Director of Public Health • �' Town of Barnstable �oF Regulatory Services °.O Thomas F. Geiler,Director STABLE, MASS. Public Health Division Y Fk3q, 1e 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 III GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT S NAME OF ESTABLISHMENT i. ADDRESS OF ESTABLISHMENT 3#2- TELEPHONE NUMBERU� "' � SOLE OWNER: V YES 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 Fi�A RESTRICTIONS: HOME ADDRESS �-- Kit Pk .P� 4� -O?k:45- HOME TELEPHONE# ' :3 fn2 CoA I�} :h Number Fee 141 THE COMMONWEALTH OF MASSACHUSETTS $1oo.00 Town of Barnstable Board of Health This is to Certify that Dip & Strip 32 Baxter Rd. Unit 2, MA 02601 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 June 30, 2007 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN SUMNER KAUFMAN,M.S.P.H. June 30, 2006 PAUL J. CANNIFF,D.M.D. THOMAS A.MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable Ofd> 4 lot Q - Regulatory Services Thomas F. Geiler,Director yry {` Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-8624644 Fax:.508-790-6304 . i Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO. DATE APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN III GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT MsP4 2C;D:k NAME OF ESTABLISHMENT �, J i �\ 1 1 L ADDRESS OF ESTABLISHMENT301 2QzQ/ 7cA L4\ ` -4— TELEPHONE NUMBER �1� 7;�'_70 -/ / SOLE OWNER ✓YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: - I t`w T IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER CLERK OF APPLI ANT RESTRICTIONS. HOTME ADDaaEss o� oN 'ffa HOME TELEPHONE.# 3 Hzz.dow'wp!q 4 MAIL-IN REQUESTS Please mail the completed application form to the address below. Also include copies of your employees food sanitation training certificates. In addition, please include the required fee amount (see fees at bottom of this page). 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 copies of your employees food sanitation training certificates. In addition, you must mail the required fee amount (see fees at bottom of this page). 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. a For further assistance on any item above, call (508) 862-4644 Back to Main Public Health Division Pajae i FELS /MOTELS RESTAURANTS BED & BREAKFASTS d WHOLESALE SHIRTS ti SAIL WASHING X Y` BARNSTABLE LAUNDRY CO. INC. PETER H.ERART PRESIDENT 32 BAXTER ROAD TEL 508.771.5044 HYANNIS,MA 02601 888.455.5044 laundry@capecod.net FAX 508.775.8585 � COPY Date:y/mil &`/ TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAMEOFBUSINESS: �rtc. BUSINESS LOCATION: 1 -s �—.MAILING ADDRESS: INVENTORY•TOTAL AMOUNT: TELEPHONE NUMBER: 5_Dg-- —7� / -- 5a y� CONTACT PERSON: a it EMERGENCY CONTACT TELEPHONE NUMBER: TYPEOFBUSINESS: F'It{E Dt57�1C-T OTHER INFORMATION: Ica (46 �l s, eLnh� vvec'-ZA- Waste Transportation: Name of Hauler: /tjm,4-yn ,. a Destination: LAJ X7 . Waste Product: au�rx4-75 Licensed? es :No ram , � �S_� _. 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. . NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Observed (gallons): Antifreeze(for gasoline or coolant systems) Drain cleaners .NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) .Diesel.fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil , NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways& garages Wood preservatives (creosote) Battery acid'(electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains,dyes PCB's Lacquer thinners Qther chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride)- Paint &varnish removers, deglossers •3*Any other products with "pow on,' labels Paint brush cleaners Floor.&furniture strippers r,7.gze.A (including chloroform, formaldehyde, Metal polishes �neT,�z4ydrochloric acid, other acids) QQ 09A Laundry soil &stain removers Other products not listed which you feel (including bleach)• may be toxic or hazardous (please list): Spot removers & cleaning fluids p g Misc.: 'D et�icae,4-ram 26. & C( c.e'k (dry-cleaners) Zo Other cleaning solvents Bug and tar removers r)e* i e.mvr WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS ta-kA seae . Town of Barnstable-Health Department Page 1 F1 HAZARDOUS MATERIALS INVENTORY SITE VISITS DBA: Barnstable Laundry Co Fax: — Corp Name: Mailing Address Location: 32 Baxter Rd.,Unit 1 Street: 32 Boxter Rd. ......... ....... ...mappar: _ City: Hyannis ontact: State: Ma i9 Telephone: 508-771-5044 Zip: 02601 Emergency: Person Interviewed: Business Contact Letter Date: Category: Inventory Site Visit Date: Type: Follow Up/Inspection Date: ❑d public water ❑ indoor floor drains ❑ outdoor surface drains license required ❑ private water ❑ indoor holding tank mdc ❑ outdoor holding tank mdc ❑ currently licensed d❑ town sewage indoor catch basin/d - --g rywell outdoor catch basin/drywell expir ❑ on-site sewage ❑ indoor on-site syste ❑ outdoor onsite system date: ....... REMARKS 5/13/02 Bleach autonatically pumped into machines. Waste compliance: water disposed into town sewer. MPS availaable. No eating& smoking in building. ORDERS: FW extinguishers need to be serviced. Need to have hot water available eye wash outdated. 4/20/04 Need to follow up on above orders. Need to inventory for HazMat license-never obtained. a>✓t.PAC. oil 2-7- a� Al S I 'r Page 2 Town of Barnstable-Health Department HAZARDOUS MATERIALS INVENTORY Chemicals: ❑ Zero Toxic Waste Materials ❑ gty's>25 Ibs dry or 50 gals liquid but less than 111 gals ❑d gty's 111 gals or more �aunit of measure --,description �M.::. cityy: - Y- ... _-.... .._.. _...__..._... -. _....... .__.............." p...........� — - -- Detergent s L.x__.Derr w Hydrogen Peroxide i Starch 3 ..__._�:_._.. ., 1 Waste Transporter: Fire District: � I S Last HW Shipment Date Waste Hauler Licensed: l �•�jC'e, 4W a', LIP /V6 L BOA �s s C �� N v r Hazardous Materials On-Site Inventory/Inspection For ALL Shops and Businesses: DBA: ��wt�4zcCit_ Location: �� • Date: 2 6-- Z) Cf Physical Features to Inspect: 1. Hazardous waste generation sites (production/manufacturing areas): 2. Waste storage areas: n,,�a�►�1�1 s �I11 eel 3. Satellite accumulation points throughout: ,U/i4 4. HazMat container storage area: 14 5. HazMat generation points: 6. Shipping and receiving areas: 7. Run down of shop activities: vv e4-L- c-ve^- w P rrn a,7145s " 8. Housekeeping practices: A10 in HazMat On-Site Inventory/Inspection: Records to Review for SQGs and CESQGs DBA: 5 .- Location: Site visit date: L(— 2-6— DV • Hazardous Waste Manifests: Al • Employee training documentation: • Hazardous substance spill control and contingency plan: to�� _ ���(,�Q�l s,�iii►�5� , • MSDS on site? • HazMat Inventory records (if applicable): • HazMat Shipping documentation: • Spill records (if applicable): /V `°F IME►oN, Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 • BABN—BLE. \\ MASS. g, 200 Main Street• Hyannis, MA 02601 i639 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT M FD MA'S� Business Name: Telt^ A—b o B\Av Date: Location/Mailing Address: e/<, Coitact Name/Phone: ��" -A-©I �o(Ony �aa�v,e c�t¢vt�wS4 t,J\kk C0 4 A-C2 54C<y OV1 Sc�2 Inventory Total Amount: / MSDS: License IF: Tier II : Labeling: Spill Plan: Oil/WaterSeparator: Floor Drains: Emergency Numbers: Storage Areas/Tanks: Emergency/Containment Equipment: Waste Generator ID: Waste Product: Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: 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 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: INF RMATION/RECOMMENDATIONS: a t>u. I e. t��e 50 t \S Ctiv)VOLVK\VA��4 ka\pwlnspector: �pww � \114 V r'c, G\�auJ� 15 Facility Representative: 4 Cl WHITE COPY- HEALTH DEPARTMENT/CANARY COPY-BUSINESS wkla1e J (e,po<3( Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 • BA MASS.LE.$` 200 Main Street• Hyannis, MA 02601 039. k i 'eoMn+ TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT i Business Name: J u � \lo,n��nva _ Date:_ s Location/Mailing Address: N. GxAP< `C r + t Contact Name/Phone: "'T(14N& Qt2 Mo.+u. Y i Inventory Total Amount: MSDS:` f License#: Tier II : Labelino: Spill Plan: Oil/WaterSeparator: Floor Drains: Emergency Numbers: Storage Areas/Tanks.� Emerc,iency/Containment Equipment: Waste Generator IDS Waste Product: Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: 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 Ji 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 i 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/RECOMMENDAT`IONS: tiVA� J\ I'` xn\.i+ i, 1[A11n%&A oOwWIAI ON O< CV0 rAofV.,. 1 --- + W0��2 1�i t`_n.A.&a.0,\t�el V) A I,),-) `6F_ -k� (1_. `'vvt-�LtvM•v�O �� v��>�Inspecto h0A � ,►l� r,, �;��, 1t a Facility Representative: Cwrti `j;1G v1J 15 } r' u.k c+.5 ti nt 5� k6 r veo( � . No),A Ci ,-° ev,v e e -WHITE COPY- HEALTH DEP RTMENT/CANARYOPY- BUSINESS. D'C,A D<- A TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM Mail To: NAME OF BUSINESS: tz- �N e- Board of Health MAILING ADDRESS: 3,;)' Town of Barnstable TELEPHONE NUMBER: P.O. Box 534 CONTACT PERSON: t 6, C--��,- Hyannis, MA 02601 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalling, at any time, more than 50 _gallons liquid volume or 25 pounds dry weight? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the .enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous characteristics and must be registered when stored in quantities totalling more than 50 gallons liquid volume or 25 pounds dry weight. Please put a check beside each product that you store: Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid ,----Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils toad Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers 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) L-*"- Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) I Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business 4 _ _•r.- -•,e$.r+ y .l+r*-r_..+...a-.., �,, .,. cb,,.-w•-5.. 5,_. .. ._ .,,,.�.....•-.++4..r�t✓r{y... ,.,..r.P+�:�.-+ - TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM . . f� � Mail To: NAME OF BUSINESS: G-- / Board-of Health MAILING ADDRESS: �l�� � �' Town of Barnstable TELEPHONE NUMBER: P.O. Box 534 CONTACT PERSON: �)� �-��v ' Hyannis, MA 02601 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalling, at anytime, more than 50 gallons liquid volume or 25 pounds dry weight? YES ✓NO } This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous characteristics and must be registered when stored in quantities totalling more than 50 gallons liquid volume or 25 pounds dry weight. Please put a check beside each.product that you store: Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants _ Motor oils/waste oils L 'Road Salt (Halite) Gasoline, Jet fuel Refrigerants 3 Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers,and developers) . Degreasers for driveways& garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda 'Car waxes and polishes Jewelry cleaners. Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint& lacquer thinners PCB's Paint & varnish removers, deglossers 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) V�c-7Ex bex Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy- Health Department/ Canary Copy-Business 1 VYY f1RN ' L`L PC?RIVCL'7—"—` CC.l�3� :'I:—Ft�IIi�C�Cfds :3�csttuy .c.,E.ai. "' ' � •• 2. Printers BOARD OF H EA Lf H O satisfactory 3. Auto Body Shops _ unsatisfactory_ 4. Manufacturers COMPANY ��`� �•-� r �`� (see"Orders't) S. Retail Stores 6. Fuel Suppliers f" . ADDRESS > �. Class: 7. Miscellaneous QUANTITIES AND STORAGE (IN=indoors; OUT=outdoor � Case lots t Drums AboveTanks Undetground Tanks MAJOR MATERIALS �,�'� ' IN UT I 0- I N gallons e [rest Fuels: � ' Gasoline, Jet' Fuel (A) Diesel, Kerosene, 02 (B) Heavy Oils: �7 waste motor oil O r - new motor oil (C) transmission/jyd uli Synthetic Org;�3-e-s-:---`� �p ! degreaser§ j A 1 41, ex �rr Miscellaneous: or DISPOSAL RECLANAATION MEMEM RE .RKS: 1. Sanitary Sewage 2. Wat Supply OTown Sewer ubl i.c -site `0 Private 3.. Indoor Floor Drains: YES NO7L • ------ Holding tank: MDC O Catch basin/Dry well On-site system a •___._�_._._... ` .___ _ __ �/ _ 4. Outdoor Surface drains:YlS NO 0 Holding• tank: MDC �,�Z Al ' O Catch basin/Dry well OOn-site system �� - .. _ —_—� ----- S. Waste Transport Ier gg — rN Licensed? ' o AB w1—A Product , 12 .21 01 Person(s)t,In't.erviewe3— U Inspector Date Fire Department retains original application and issues duplicate as Permit fZG�IPr�- ' �elia�xfii��ento�C- �'axs�i�uir��—�acvXr.�a�C�rixs�x�e'ntian 5���f— APPLICATION and PERMIT Fee: for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L Chapter 148, Section 38A,527 CMR 9.00, application is hereby made by:" Tank Owner Name(please print) A, A6MZS blow ,tom. _ x Address i3a),4 l _ W__ street Cay sate r l Mimi Company Name 2 i -Co.or Indnridual Address Address ° ✓'�`'^* i Pft Signature(ifip lying for�p Signature g ( applying for permit) ' ❑ rtffied Other ❑ IFCI'Certified ❑ LSP: Other Tank Location StWAddM= CRY Tank'Capacity(gallons) -'� U '.�--- Substance last Stored T'c � _ Tank Dimensions(diameter x length) Remarks: 9 • a reTri It F.9• Firm transporting waste State Lic.# .? Hazardous waste manifest# EPA# Approved tank disposal yard Tank yard# 0+`z.✓ Type of inert gas Tank yard address fSE_X ,,O 57 + 11 1 �C�lfc.A City or Town � f Ti✓/��-f MID* ���r�� Permit# Date of'issue Date of expiration Dig safe approval number: _ Ti B� g Safe Tall Free_ Tel.Number-800-322-4844 U C B D-jPART1YiFdV Signature/Title of Officer FIRE-RFS .�.�n AD. �� n After removel(s)(`Consumptive Use°fuel oil tanks exempted)send Form FP-2908 signed by Local Fire Department to Office of the State Fire Marshal,UST Regulatory Compliance UniL P.O.Box 1025,Stow,MA 01775. 'international Fire Code Institute 292(revised 4197) TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM Mail To: NAME OF BUSINESS: Board of Health MAILING ADDRESS: Town of Barnstable TELEPHONE NUMBER: `-7 3--7 om P.O. Box 534 CONTACT PERSON: Hyannis, MA 02601 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quanta s totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES �O This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of,Health has determined that the following products exhibit toxic or hazardous characteristics and must,be registered when store §� Please put a check beside each product that you store: Antifreeze (for, gasoline or'coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator-flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils . 4 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 __A,�� Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes W4 aints, varnishes, stains, dyes Fertilizers (if stored'outdoors)- paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Faint brush cleaners (inc. carbon tetrachloride) loor & furniture strippers --ZAny 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 OF BARNSTABLECOMPLIANCE: CLASS 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops �a O unsatisfactory- 4.Manufacturers COMPANY ✓ (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS ��� lass: 7.Miscellaneous Q ANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel(A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) n'new motor oil ( ) transmission/hydraulic Synthetic Organics: degreasers Ix- 744_'�_4.4 i:4— iscellaneo.us: L i DISPOSAURECLAMATION R MARKS: 1. Sanitary Sewage 2.Water Supply ;Town Sewer Public r O On-site OPrivate d 3. Indoor Floor Drains YES NO O Holding tank:MDC O Catch basin/Dry well L O On-site system 4. Outdoor Surface drains:YES-NO ORDERS: O Holding tank:MDC Catch basin/Dry well On-site system 5.Waste Transporter Name of Hauler Destination Waste Product YES INO v 2. s � Pers (s) Interviewed Inspector Date �C011PLIANCB: CLASS 1. Marine,Gas Stati'ons,REpa TOWN OF BARNSTABLE � sa ac 2' Printers �( Q tisftory [TMR OF HEALTH r 3. Auto Body' Shops Q unsatisfactory- 4. Manufacturers COMPANY AM I P � �c�I� (see"Orders") S. Retail Stores 6. Fuel Suppliers ADDRESS (A)IS -IM, :ay—A Y,11S Class: 7 7. Miscellaneous V 4 QUANTITIES AND STORAGE (IN3lndoors; OUTaloutdoor. MAJOR MATERIALS- Case - lots Drums AbUveTanks Undetgrohod Tanks id )1 4llZ ___"a lions 9M Enj Fuels: • Gasoline, Jet Fuel (A) Diesel �„Kerosene# 12 (B) i 1 s Heavy O : N ,- waste motor oil (C) new motor oil (C) transmission/hydraulic Synihetl.c Organics: degreasers .Miscellaneous: CAI f4 � ?ell uC'�C� ISPOSAL REC , MAT ON MUMS: rn� (' (�'��y,'' 1. SanitaryD $ Sewage 2. Water Supply MODS�/. S D` � 'L'`" rr '� �'f k� s ,� f : r Town Sewer Public Y ALL-• O on-site Q Private 3. Indoor Floor Drains: YES NO IV Q [folding tank: MDc � . � �t)�` _�Oofi r� �C�PiM/ Catch basin/Dry well On-site system F-/A fn ;W 4. Outdoor Surface drains:YES NO MD C ����0Ifoldint,tank: V1Jr�l �. gEc.,vC ' OCatch basin/Dry well __... _- -- OOn-site system S. Waste Transporter Licensed? Ns2m �jj�illgl� DeStinatinn Waste Product- 2r 2C ,r---r Kc,,� JO u e: Verson(s) Int.erviewe �` �` / Inspector Date r