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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: 0 e,Lm V, 4, • „S` Mail To:
��-' Board of Health
MAILING ADDRESS: Sp Town of Barnstable
TELEPHONE NUMBER: P.O. Box 534
CONTACT PERSON:
Hyannis, MA 02601
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Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totallip@, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NO V
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 i
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
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) ;�Jt3'
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy- Health Department/ Canary Copy-Business
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 lots Drums Above Tanks Underground Tanks
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline,Jet Fuel (A)
Diesel, Kerosene,,,#22((B`) �^
1-00
waste
new motor oil(C)
transmission/hydraulic
Synthetic Organics:
degreasers
Miscellaneous:
�DISPOSALIRE(,LAMATION REMARKS:
�1. nitary Sewage 2.Water Supply
Town Sewer (2(Public
O On-site OPrivate
O 0
V3. Indoor Floor Drains YES_—NO I/
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
1/ 4. Outdoor Surface drains:YES NO_/ ORDERS:
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
t/!o Waste Transporter
Name of Hauler Destination Waste Product
YES 0
��e son (s) Interviewed -InApect6r Date