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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS: CA9e J ESLAY S Llllj Board of Health
MAILING ADDRESS: Ca 5_ CQ23V Stn-U%E" , �hnn °s �_/I Town of Barnstable
TELEPHONE NUMBER:' 04r'` aOD P.O. Box 534
CONTACT PERSON:
Hyannis, MA 02601
�i �'�e�s� /�si��.��
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totallin , 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
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
a �
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)
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 (in 'n chloroform, formaldehyde,
Laundry soil & stain removers ( hydrochloric cid, other acids)
(includin bleach Other products not listed which you feel may
Spot removers& cleaning fluids be toxic or hazardous (please list):
(dry cleaners) S A
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy- Health Department/ Canary Copy-Business
TOWN OF BARNST ABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
2. nters
BOARD OF HEALTH O satisfactory 3.Auto Body Shops
O
unsatisfactory- 4.Manufacturers
COMPANY CP +-T5(Ands l j (see"Orders") 5.Retail Stores
e-� 6.Fuel Suppliers
VAA DDRESS 6 �-- 1 nnh1 S(44 Class: / 7.Miscellaneous
QUAN IIES AND STORAGE (IN= indoors; OUT=outdoors)
ATAJOR MATERIALS Case lots Drurns Above Tanks Underground Tanks
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels
Gaso 'ne,Jet Fuel
Diesel, erose/e, 2 (B)
Heavy ls:
waste oto oil (C)
new mot r oil (C)
tran issi n/hydraulic
Syn etic O anics:
egreasers
Misc laneous:
. 25A V
/� ISPOSAURECLAMATION REMARKS:
1. Sanitary Sewage 2.Water Supply
Town Sewer Public
O On-site OPrivate
V. 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
DestinationName of Hauler
1. 1<s Jt� r is oG�2111t� td -6 jl'4 eV g YES N0
Person (s) Interviewed Inspector Date
V �- 7 z,�'�