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Home My WebLink About0018 CENTER STREET - HAZMAT ig its r i i i i i i i I i S M E A D KEEPING YOU ORGANIZED No. 10334 2.153L MADE IN USA GET ORGANIZED AT SMEAD.COM TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM Mail To: NAME OF BUSINESS: gq4 g-7-JO& Board of Health MAILING ADDRESS: z Town of Barnstable TELEPHONE NUMBER: P.O. Box 534 �" Hyannis, MA 02601 CONTACT PERSON: 5_'V- g4At /rf40Z' � 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 ' 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) Paint & lacquer thinners,, PCB's Z 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) rca(r-Fh 1__3Gr3 Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy- Health Department/ Canary Copy-Business it TOWN OF BARNSTABLEfr ,atigfattory----- MPLIANCE: CLASS: 1.,Marine,Gas Stations,Repair tisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops • ^ - 4:Agam►u€actuens ...- COMPANY (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS / lass: 7.Miscellaneous / QtuTiFIE- S AND STORAGE (IN=indoors; OUT=outdoors) MAJOR MATERIALS 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) f new motor oil(C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: L ' i DISPOSALIRECLAMATION RE=S: 1. Sanitary Sewage 2.Water Suppl "& y Town Sewer ublic O On-site OPrivate 3. Indoor Floor Drains YES 1 NO O Holding tank:MDC Q Catch basin/Dry well Q 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 Name of Hauler Destination Waste Product YES NO 2. . FI Person (s) In erviewed Inspector Date TOWN ' OF C3ARNSTAI3LE COMPLIANCHI CLASS; 1. Marine,Gas Stations,Rtpair Qory satisfact 2. Printers CT�I�R • OF HEALTH � � 3. tuto P,ody Slops Q unsatisfactory- 4. tanufacturers P/ i�j� (see"Orders") S. Retail Stores COMPANY' `` �- �` - _ 6. Fuel Suppliers ADDR@SS. (� /,IT�;' - % ,�� ,11 Class: ry� 7., Miscellaneous -- J QUANTITIES AND STORAGE (IN-ludoors; OUT-outdoor. MAJOR MATERIALS- In— Drums AboveTanks Undetgr.ottnd Tanks I� �t OUT I A gellolls 9M Ent Fuels: • Gasoline, Jet Fuel (A) Diesel, Kerosene$ 02 (B) . Heavy Oils: waste motor oil - (C) new motor oil (C) transmission/hydraulic - Syntheti.c Organics: degreasers • Miscellaneous: a h _ n a � f' c r i AZ} ISPOSAL RECL MAT ON RE1`u,RKS: 1. Sanitary Sewage 2. Water Supply Q Town Sewery Public r QOn-site tQ Private �+ � - 3. Indoor Floor Drains: YES N0 C � G !��" fn _ Holding tank: MDC O Catch basin/Dry well On-site system 41AW Y rl—k-x" iV�' ��%� c.; 4. Outdoor Surface drains:YES NO 0 HoldinL tank: MDC o }} Catch basin/Dry well rr O On-site system i-ir"1 VC'- ! I �,% _ : .��', � !el __ S. Waste Transporter - - Licensed? t-Nam""auium 3lfnste Product. 2 r ' L u et Person s interviewed Inspector Date IKE r°w� Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 "M�`E ' 200 Main Street• Hyannis, MA 02601 �'DrFOnnF�°�0� TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT --1 Business Name: k,w ask Date: 1 Location/Mailing Add ss: 11b CP-At-r > Q�� S Contact Name/Phone: \j�n�� 1. S- -7'1 \ - ms l Inventory Total Amount: /-2-5-To-1 MSDS: Oe•- nok ewl License#: Tier II : o Labelin : o b -,1 Spill Plan: I — O l/WaterSeparator: AVA Floor Drains: J0 Emergency Numbers: V Storage Areas/Tanks: 4a-I eoVt+a 114er S Emer enc /Containment Equipment: Waste Generator ID: AJA Waste Product: A 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: INFORMATION/REC MMENDATIONS: o �►� , �v� Co �� Inspector: Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS oFt rok y Town of Barnstable '" Office:508-862-4644 I! Public Health Division Fax:508-790-6304 {BARNSTABLE. ` . MASS 200 Main Street• Hyannis, MA 02601 ! i639• ♦0 A s r TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT t Business Name: 11\t Date: Location/Mailing Address: ,�b (U_vl e—r Contact Name/Phone: )urtn.r 51 �, ak 5 Z>-1-7-1 - OV5 1 Inventory Total Amount: C ZS 0. MSDS: CeA%,1 a%&I-) License#: Tier I[ : AID Labeling: Spill Plan: enc Oil/VNaterSeparator: x�lA Floor Drains: J0 Emergency Y Numbers: Storage Areas/Tanks: I �!-L An v �� I cad%tif f* ar�f Emergency/Containment Equipment: Waste Generator ID: A f iA Waste Product: AYA 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) r/a Windshield wash Motor oils ,f 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: t INFORMATION/RECOMMENDATIONS: e..In w,,L re-, Inspector: (- Facility Representative: WHITE COPY-HEALTH DEPARTMENT/.CANARY COPY-BUSINESS a TC Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 (' B`"M� 200 Main Street• Hyannis, MA 02601 1639. �prEDMn+A,O TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: Ya M r s V.'A Date: 8 ► i Location/Mailin Address: 18 C-ciAA-et 5+ . ,r a-n v,-ti s Contact Name/Phone: A Inventory Total Amount: <� MSDS: aA bw1 License#: Tier II : Labeling: Cc a-t Spill Plan: Oil/WaterSeparator: Floor Drains: A 0 Emergency Numbers: o1K Storage Areas/Tanks: x q&AS yvV4 -4-W 6, a,1 ack4- Emer enc /Containment ui ment: Waste Generator ID: IN Waste Product: Date&Amount of LasAhi ment/Fre uenc : 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 Z- Other cleaning solvents&spot removers 7- Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) 3 Windshield wash 3 Motor oils I Miscellaneous Corrosives I e rar-o Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants I +I Miscellaneous petroleum products: 1 o b Road salts Sbjb X 5c> 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 ti Miscellaneous Combustible Z 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) y -�v J.s\• Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECOMMENDATIONS: c> Inspector-- -C�LA`�Ae, Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS j TOWN OF BARNSTABLE Date: </ q y s ��;o� TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: Nyanyi f s t-660,, -eA- BUSINESS LOCATION: 54- INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: *'-77!— Olo ! 1. \\ a010x.s CONTACT PERSON: �'��- S', k- ,qyr /on,s EMERGENCY CONTACT TEL PHO E NUMBER: MSDS ON SITE? TYPE OF BUSINESS: o- -eo\ yvVP—y%%eAG2 INFORMATION/RECOMMEND TIONS: o Firg District: sa'`n"! 1 '1K VI, 1 5 Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes 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. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) y Miscellaneous Corrosive z ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants 51, 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 2 Miscellaneous Combustible 1 +l Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) y Miscellaneous. Flammables 7.+2 Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes �I Laundry soil &stain removers Z- (including bleach) 3.1-Z"L Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents 1 4- Bug and tar removers S Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials