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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
� v c •� l��c� � Mail To:
NAME OF BUSINESS: � Board of Health
MAILING ADDRESS: L S ���������� �G� 14i1,'>r17iS Town of Barnstable
TELEPHONE NUMBER: �� ��e�' P.O. Box 534
CONTACT PERSON: ��k '� r� r (C-�T POA. e�a 1_5 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 iri ' d
Please put a check beside each product that you store:
V Antifreeze (for gasoline or coolant systems) v Drain cleaners
f/ Automatic transmission fluid Toilet cleaners
` Engine and radiator flushes Cesspool cleaners
y Hydraulic fluid (including brake fluid) y Disinfectants
Mot�ils/waste _oils Road Salt (Halite)
V Gasoline,odeHail- Refrigerants
Diesel fuel, ke=ene, #2 heatin oil '✓ Pesticides (insecticides, herbic'
Other petroleum products: 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
Fertilizers If stored outdoors
Paints, varnishes, stains,�s (' )
Paint & lacquer thinners PCB's
Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
V 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 Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy-Health Department/ Canary Copy-Business
r
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
BOARD OF HEALTH O satisfactory 2.3Printers
.Auto Body Shops
J O unsatisfactory- 4.Manufacturers
COMPANY see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS 95 5' W.V Class: 7.Miscellaneous
QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS Case lots Drums Above Tanks Underground
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels: 1
Gasoline,,)
Diesel, Kerosene, #2 (B) f1�'A ti
Heavy Oils:
s
waste motor oil (C)
new motor oil(C)
/tee-a/fv2--y���.L6n
transnfission/hydraulic '
Synthetic Organics:
degreasers
a"'qe het
Miscellaneo s:
h 'Lp��:�; i s
GAC-4 WAX,0,-)
3P),A c" � , •
A f ;
VA few;fps'
I 1
�.fe'ry �,
r&rr-o ` .4x4'e. <go&16V
DISPOSAURECLAMATION REMARKS.
1. Sanitary Sewage 2.Water Supplyi
O Town Sewer OPublic � ��f ,, 46
XOn-site OPrivate
3. Indoor Floor Drains YES NO
Holding tank:MDC [ -
O Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YES N0—Z ORDERS:
O Holding tank: MDC s
O Catch basin/Dry well �.
O On-site system
5.Waste Transporter
, • of Hauler Destination Waste Product
r�
YES NO
2. `vY �x
" Person (s) Interviewed Inspec or Date
L_ ,
i
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body Shops
O unsatisfactory- 4.Manufacturers
COMPANY (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS Class: 7.Miscellaneous
QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS Case I ots Drums Above Tanks Underground Tanks 'i
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline,Jet Fuel(A)
A Oe
vg
Diesel, Kerosene, #2 )
Heavy Oils:
waste motor oil (C)
new motor oil(C)
transmission/hydraulic
'Synt�etic Organ
degr sers �. /2 l✓
Miscellaneous: I .
4_5
DISPOS EC;LAMATION REMARKS: AA
1. Sanitary Sewage 2.Water Supply � `Y �
O Town Sewer OPublic e_4st, -4 <
O On-site OPrivate
3. Indoor Floor Drains YES NO
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YES NO ORDERS:
O Holding tank: MDC
O Catch basin/Dry well
O On-site system
5.Waste Transporter
Name of Hauler Destination Waste Product
YES NO
1.
2.
z 1%� �� o
Person (s) Interviewed Insp ctor Date
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH O 3.Auto Body Shops
O unsatisfactory- 4.Manufacturers
COMPANY (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS Class: 1 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:
Ga oline,Jet Fuel(A)
Diesel, Kerosene, #(B� )J I/
Heavy Oils:
waste motor oil (C)
n
new motor oil (C) /$`3 _1A y
tp/J transmission/hydraulic
Synthetic Organics:
degreasers —
22
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aw�E�42�6-S 7�
O M sce ane s�,
r �✓z—'G 7
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DISPOSAURECLAMATION REMARKS:
1. Sanitary Sewage 2.Water Supply
O Town Sewer OPublic
O On-site OPrivate
3. Indoor Floor Drains YES NO
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YES NO ORDERS:
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
5.Waste Transporter
Name of Hauler Destination Waste Product Licensed?
YES NO
2.
Person Cs7Interviewed nspe( Dat �