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0002 IRVING AVENUE - HAZMAT
Iry f a me_.., f ,GCo ��� ��Yh►�� 2(Ilfat �rnY, (�e-,\ls i Number Fee 1153 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that HYANNISPORT CLUB INC. 62 MARCHANT MILL ROAD, 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 r� l i` f .f Town of Barnstable Regulatory Services Richard V. Scali,Director # Y x s `" MASS.M ' Public Health Division �Qj tG39. `fig' ArED MA'1 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.2 DATE 6/-3o/ /� APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT A/Rrral i ze' Z NAME OF ESTABLISHMENT Coo y�/a-�`mot fie.����z e ADDRESS OF ESTABLISHMENT 60 TELEPHONE NUMBER k P) 7 ? SOLE OWNER: YES NO PQeQ x 3L 2" IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: b Z b?2 IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. 0 4f STATE OF INCORPORATION FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER CLERK ,. SIGNATURE OF APPPLICANT f Cad(�Ce�r� l/y/czs�re 5c7 RESTRICTIONS: HOME ADDRESS HOME TELEPHONE# C:\cache\Temporary Internet Fi1es\0LKD3\HAZAPP ReQ015.DOC r Town of Barnstable Office: 508-862-4644 Regulatory Services Department Fax: 508-790-6304 . BAV"N' ream ; Public Health Division MASS. Thomas A. McKean,CHO � n .��►` 200 Main Street, Hyannis, MA 02601 Payment Receipt ,Hazardous Materials Payment received: $100.00 (Check) on 7/20/2015 Permit number: 1153 i iCheck number: 24826 Check amount: $100.00 Name on check: Hyannisport Club, Inc. !Business: HYANNISPORT CLUB INC. jAddress: 2 IRVING AVENUE, Hyannis Number Fee 1153 THE COMMONWEALTH OF MASSACHUSETTS $100.00 Town of Barnstable Board of Health This is to Certify that HYANNISPORT CLUB INC. 62 MARCHANT MILL ROAD, HYANNIS,MA 02672 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. 5/1/2014 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable Barnstable Regulatory Services Department AHmWcaCft 1ARN9TAHLE. Public Health Division I 9MAS& 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 `J� 1, Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO Application Fee: $100.00 kn4P parel ASSESSORS MAP AND PARCEL NO. �-� _ 3 DATE `�( ���� APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT i ll NAME OF ESTABLISHMENT &00415 9® Tf ADDRESS OF ESTABLISHMENT a' q�G G/crvr7L �� `� t�o r,t' TELEPHONE NUMBER 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 14 Iot5_5 r-c G l2 se 7- FULL NAME AND HOME DRESS OF: PRESIDENT mho 6:2- �a�e26Pir e,- 02..- J vrh Ale a nis m�f t�?G TREASURER " 1411 CLERK Aq2.t�' Vx OCR D gKis �rv,t'.r t4de }��rahHis�o f ws SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS t�l q Prot f '✓t r`l� oLT HOME TELEPHONE# O S 7-7S- S/ J:\inspection handouts\Haz Mat Application200800C IB roh� Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 BARN LE 200 Main Street• Hyannis, MA 02601 �A'FOMP+a` TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: PVAVhA i g orb' (9'OW Date: Location/Mailing_Address: 6 2 +t t'� sA l 1 cc✓ri f s o� MR�I D Z Contact Name/Phone: m vim., Qe,I&"-,i> - ,na Ar Ryan , Fr ,,k-Awle-k. `' e}�'1va.lslti Inve to Total Amount: S -�' w"�- 4- MSDS: ,t, ��s� "" Jsk-`t'46 License#: 10�5 C'�3 �000 l� t Tier II OD Labeling: j,749 Spill Plan: Oil/WaterSeparator: wP�u Cec y�lQ� Floor Drains: s I� IDS 1 Emergency Numbers: e,S Storage Areas/Tanks: Soo : a( W Jda�� Emergency/Containment Equipment: �`�� V4,% 3 4K 44!2�u-a-V1 ors, t",00-+ra.lclGl,es,J A'S'T �y Waste Generator ID: Waste Product: ` \.o Date&Amount of Last Shipment/Frequency: 50e t �t 1icensed Waste Hauler&Destination: Other Waste Disposal Methods: N LIST OF TOXIC AND HAZARDOUS MATERIALS `� NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws bf MA, hazardous matIrial 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/RECOMMENDATIONS: A, a,"k ' -V 00 A I I w Q Inspector. aFacility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY- BUSINESS �" �._x. r?"i `3��Z't`.� .`3a...f#g433 .�.�7 f L/G✓vV. D l`1 � l�� Please prin0r type.(Form designed for use on elite(1 2-pitch)typewriter.) V- Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 14." n N beWASTE MANIFEST" . .g �z£ r� 33 V/\V 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) awl S Generators Phone:' 6 Transporter 1 Company Name y U.S.EPA ID Number # `fi X �.s%MMEI i d-i`.I I# 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated,Facifity Name and.Sde Address T- U.S.EPA ID Number KLE 01--.f Facility's Phone: 9a, 9b.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers %Total 12.Unit 73.Waste Codes HM and Paddng Group(if any)) - y No. Type Quantity WLNd. y 1•'fT"' f (x Q31 it ¢D'St''.5�/ '} s$ Yi8 z 2. W C7 3. 4. 14.Special Handling Instructions and Add#tidnal information # r .,. 01,_ai7 R i,Y-fir'. z' _ �._...- F'1' .6Pi } >w:#3s.tr.Ss# 1.ebi a�p a �ti `y 2 .., "��1`!F:K i ;ai.?'-4 R f��sE`N�3- 3 t fP ..T3 g;V-f`a i tj i T-,"P ::g 'qf t,'4 :s� RT .R ' '?r 15. GENERATOR'SIOFFEROWS CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately desc lW above by the proper stripping name,and are ossified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.if export shipment and I am the Primary Exporter.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of CornsenL I certify that the waste minimization statement identified in 40 CFR 26227(a)(d I am a large quantity generator)or(b)('d I am a small quantity generator)is true. Generators/Oifeemrs Pnr#ted/typed Namer� Skpatwe y Month Da Yea 4 j 16.International Shipments H ❑Import to U.S., ❑Export horn U.e Port of entry/exit Transporter signature(for exports only): Date leaving U.S.: w 17:Transporter Acknowtedgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Da Year p (GJj ti a a Transporter 2 Printed/Typed Name Signature, t. Month Day Year 18.Discrepancy;. .. I Be.Discrepancy indication Space ❑ Quantity O Type \:m Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Altemate Facifity,(or Generator) U.S.EPA ID Number ua- Facility's Phone:_ W 18c.Signature of Alternate Facility(or Generator) Month Day Year a • N19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedgyped Name Signature Month Day Year EPA Form 8700-22 fRev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA , E �i' ICI', ��I;I I~7� Pie,asepnntior pe,(Form,ceslgned for;use on elite(12 Fitch)typewriter.) Form Approved.OMB No.2050-0039 N ns,«,r u w i Nµ u 1.Generator ID Numbe, 2.Page 1 of -3:Emergency Response Phone d.Manifest Tracking Number NIF,OR H R O,JS 1 �� �p br`b'9 I•hl II g't�' 4 e 7__' sr; b I��LWAS M �MIFEST Pr1s1 c F: � �.~ 1 bF,fw�-' r vs 6� it i 5'IGer 64ato s(I"Ene an'd Mailing Address Generator's Site Address(if different than mailing address) { l ILI k' (z t'' C 3.sib 1.'11 '711 " Generators ill! 1 'raft;. E t 4 cti ' 6 ITrahsoo eri1 i"'o parry Name ;' U.S.EPA ID Number I it , IF (� - I Y'ITEMS,C;# v' 1K, �!'�(IR00?081 05 I I ppJJ 4 _,...._ rr� c t Iir+ 'If�tl li �`. 7�Trarispo er 2 mpan'y Name P U.S.EPA ID NumberU+ �rlll�lilr�� ,Designa ed facility Nane and Site Address Yy' U.S.EPA'ID'Number . ! I. r Vo.�1 i '.s i: � 3 f�4-:e ..Fq% t I i r" IMILL Ell RED.a ('RA S�A(�•N I ? 2`05' pI, .I) 'll :tts i4:sl. i71 Faplllty s F o g A r1 „F!� I h I r l Pa. ;I 9� S OT Description(includinc Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit ( t 'u �A I' l r 13.Waste Codes ( �M� a Pads ngroup(if any)) f I I I No. Type Quantity Wt.Nol. 1 r( I1I I w li I i I 6FkI'' Qi�Q IL { ppt �� f }( 7 ]t x'O (.lei i..WASTE.- I�,I.#tt'E�E)••�T C�Y r t-��4a.�)?:y F'bn J .°a( hAd`E 6 tJl:J5.9 (: tC t'U I•t ��I€IA I Fi4?) t # I r. I FKq I • .Z 311 i (II j s I t i P s �~ III Ir ( t l I g; I y Additional Informatlo� { ., 1 ,.' ._)_.. ._ _.... ( t;5.335"'S4l:t_ _..__.__. 7,:�'"i.,�l,.i...t.E_ .,. .3.i?vL•' i.�','`Ji�„--_-____-.. __ .._.i'_.,�i�_a �t3�f. 33 (( 14 S"e lal an'in InstrjctionsandA.' i�Y{ 11 A A.AT 6*'i^t'BA it 'lA :AE-'ft .Ti tC4 Wtd'�'A^1'lf-h.4 E Y #8 3-•zR. C's¢.54A. rv,-enn. •nA. A:c^rnr•..r+n v FEROR'S CERTIFICATION:`[hereb'y declare'that the'confents of ails co"n`signment are filly and accuYately`escriti"ed'above`tSy the"pr Jrd shipping name,and are classified,packaged, �'' nuls E + ,� � v i markke �an )alt eledhlacarded,and are in all respects in proper condition for transport according.to applicable intematignal arad f°iationaf goyernmental regulations.If export shipment and I am the-Primary n. II(xpon (k�.. aiiLLMM I. EI _ Ifo lcrtl rithll mEwt of �he��(�asltetmlmmi cont�osn�statement Bert fiedcnn40 mFR to t262.27 a he terms�if I amthe laree Euan cknenere9or or b C f I am a s ally uanh enerator?is true. ,btc, I a O( 9 Q tyg ) ,(,)( , mal9, ityg II, Generratorsl ffe`, FePririted/Typed,Na ne s Signature r t , Month Day Year o =1 1 ��� ,� i r I '�; 16 Ilhfema i nal ss h pdrd6"s I �1 ( ❑Import to U.S. ❑Export from U.S. Port of entry/exit: 4 ? gTrarisporte'Isigr' rel(forexportsonly); j Date leaving U.S.: 't Awxn'- ' it IIW 1,1 Tlranspo le. :n�wlecgment of Receipt of Materials d ;•} I Tran sp'rt r P' ted yped Name ! Signature Month Day Year 1 i II r'- O Z 7Trarisporter 2�r�tddljiirypired Name i Signature Month Day Year 18 Discrepancy liI�� f I 18a'Dlsc�elranc"nd cation Space ,, ❑Type ❑`Residue ❑Partial Rejection Full Rejection +;❑ Quantity yP ❑ 1 l Its "I j, •. Manifest;Reference.Number: q� ii >• Bb;lAltem te'F curly(or Generator) I`, i U.S.EPA ID Number ' ki s ,. w ;18c'Signal re d Alte'mate Facility(or Generator) Month Day Year ; N i� 1'Id lI IA YI Ifl�1 I. "�• 91 0Hazard us�! asteiReport Management Method Codes(i,e.,codes for hazardous waste treatment,disposal,and recycling systems) r u Q tflk i� I. II' 2. 3. 4. V . tI I f;, i 20 IDesign ted :*clifty wner or Operator:Certification of ireceiRt of hazardous materials covered by the manifestlxce�p�a mootf./ ed in Item 18a Printed/T d N""e f + Signature,"{ f/ Month Day Year z' EPAFolmrr 01� 2 Rev.3-15) Previous editions are obsolete: bESIGNATED FACILITYTO CaENtRATOR` i'+ I E Ik riA ( 11ff ntli �I f'lll!i Number Fee 1153 THE COMMONWEALTH OF MASSACHUSETTS $15o.00 Town of Barnstable Board of Health This is to Certify that HYANNISPORT CLUB INC. 62 MARCHANT MILL ROAD, 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 f Town of Barnstable Regulatory Services Richard V. Scali,Director .�,_ :,R�t, z MSEL �p' Public Health Division BARNTSTI�BLE 16�3A�1Y�' Thomas McKean,Director .o 200 Main Street,Hyannis;MA 02601 ro Office: 508-862-4644 d Fax: 508-790-6304 P W 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 A late charge of$10.00 will be assessed if payment is not received by July lst. ASSESSORS MAP AND PARCEL NO. � �✓?' ° DATE FULL NAME OF APPLICANT:_ 4"Wh? S.pQ r-tor C l i4 b " NAME OF ESTABLISHMENT: a d I i- !�"!�t �'!��yJ 2�1 GG 94r e �Gt�e�?9 ADDRESS OF ESTABLISHMENT: CQ O �jYjc�rG,Gj a.�'� Yyli/� �o�u0' MAILING ADDRESS(IF DIFFERENT): 6 D 9) `7"7. -- S// 4i TELEPHONE NUMBER OF ESTABLISHMENT,, EMAIL-ADDRESS:: �GD 10 w 1'o v /2}y ahn r 5e.0 T`jkb �o SOLE OWNER: YES NO IF NO,NAME OF PARTNER: FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME H)/Ann j4ed r} C-[VS- 11 C. PRESIDENTo` TREASURER ,,5(,A V. CLERK=`'":, :•,� Sri rah. :c. ., �4cc,,, _ _ `°IF PREPARED BY OUTSIDE PARTY. • SIGNATURE O APPLICANT Name: Company Address : Telephone#: Email: CATemp\HAZZAPPRev16.docx Page I oft IKE tok� Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 • BARNS LE. ` 200 Main Street• Hyannis, MA 02601 163 9. a,0 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT rFD P'� Business Name: 6-0[ G1u Date• !Z 11 t� Location/Mailing Ad ress: 62 a-rc�. aw an 15 ev Ma,I : VQ,IB,5;KZ Contact Name/Phone: Al-ty- W&I.51,- o, i Co l a"e, t m 4 r> Snh--77�Si 1 1olk Inventory Total Amount: �. �� dory_ S�St,,MSDS: Y S License#: 3 Ca+ Tier II : Ivy � t Labeling: -k+o x Spill Plan: yp S Oil/WaterSeparator: Floor Drains: sa• Emer enc Numbers: Ye5 Storage Areas/Tanks: t( k t ��U �;�` C4> 4-e - c c�c ,� ktar.12 C-5-4n o� Emergency/Containment Equipment: I 1OooY-oy + Waste Generator ID: Waste Product. , DC<LC 1, CJ4e a.ve,<'• ('f�c5 Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: 5 Other Waste Pisposal Methods: 65' -% t\--' vt- w JA 4D 1 5 -VK-4J� 10(eo&AX,evT,0A, o cotIvi-b�8 .,VIU S k IQJ �l'atn,� Ioo0pal LIST OF TOXIC AND H�►ZARDOUS ARTERIALS o VWD.1cd e..��C- ��- tv��2ytkol�,/ �j I vtc� �Q`j{- 1n5 ovCr; NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous rhaterial 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) JAsphalt&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/RECOMMENDATIONS: �lQAJ tJ61eAC- I A92 OK-JIMQ 5 o r a -e!vla lopGlo -,,%4 •hi-v tt3ov�.�c, Clea�t.� N Inspector: 6'9o�cA A til k4-4A-1 G�b acility Representative: �« (��5��) WHITE COPY-HEALTH DEPARTMENT/CANARY COPY- BUSINESS Date: q/ S I l`� TOWN OF BARNSTABLE ,ns TOXIC AND HAZARDOUS MATERIALS FORM NAME OF BUSINESS: av+Hts eor (701C'Gob BUSINESS LOCATION: 6-2- Awc-nAwk's AM , 4Vwn -, er4- INVENTORY MAILING ADDRESS: P0 6ok -392 TOTAL AMOUNT: TELEPHONE NUMBER: YODg 1-7 Stllp CONTACT PERSON: Ik\ V.. 01 I�o,M Co�owclpo l�oos�,,�r,}ot �ribJ� by�.G EMERGENCY CONTACT ELEPHONE NUMBER: G "`a� MSDS ON SITE? TYPE OF BUSINESS: c ojF Cepoya-- Ye's INFORMATION / RECOMMENDATIONS: �Q �nc►.�c,cS ��6��5���4G Fire District: OC�614 z) d��a�l V � r I ear � wk5 14 v�A&n 11���11,f� 3) >°yKa.k Co��•c s o �a�ke.�•a�.�e s qW t� Waste Transportation: �c,Q ��`�'kG -� 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 (r4 c�„ 5,�, . o 0u4—�n ,��s �r ctr-W t:Z Cr-4 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) Miscellaneous Corrosive ❑ NEWty ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) 'S Refrigerants Motor Oils �4a1 Pesticides 0 ��� �1'6.y-3 insecticides, herbicides, rodenticides ❑ NEW ❑ USED �•1�0�'" ,+�' ( ) Gasoli oe, Jet fuel,Aviation gas 5Ilmil . Photochemicals (Fixers) Dieselyuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil S,If 7. ❑ NEW ❑ USED Degreasers for engines and metal.k 40 4j 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, Lacquer thinners (including carbon tetrachloride) ❑ NEW , ❑ USED 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 o�- Laundry soil &stain removers (including bleach) > Q-C�vt k I4o GIA"�- qa, C�vb Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials �' Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number z.4. 2.Pageii of .3.Emerr any Res onse Phopg 4.Manifest Tracking-Number (��[(� WASTE MANIFEST s rra t 4 ztrl7 c i t„fr w '`;I a zf5 ° 7 0® 4 V KS 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) Generators Phone: 508-"775--5-4.16 6.Tran§RRo���jt�ffr, ro piny 8 U.S.EPA ID Number Tr, 1! t �? f Ct� � ;if .q p`4 g, p 7 �;F "YS'.. Fla Y• r? c STEM EI`i i.:: s.Ft,. 3, r JiJ.:7. t..V.,.t 7 Trati"sporter 2 Company Name: ,. y U.S.EPA ID Number 8.Designated Facility Name and Site Address R +~.'t Iri;EN a'YcTEMS. .11C U.S.EPA ID Number Facility's Phone: ga, 9b.U.S.DOT Description(includingProper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type .Qua tity Wt.Nol.. X 1 Nrl:t. F 3 t A,'-TE r:OMBIJST!'df H s 10t.)!0' W tI. (PETROLEUM NAPHTHA) P0111 z 2. W 3. 4. 14.Special Handling Instructions and Additional Information M. Ei ERBENCY 4 800-a6S_??60�Cell^ K FT' LEF't4 4 ;3S) .S'f AIJTk{11'RIZED "`fly RETAIN LICENSED STIRS-1~t3ldW CARRIERS AS NECESSARY 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If exportshipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if am a small quantity gene ator)is tru . Gen_a tors/Offerors Printed/Typed Name Signature Month Da Ye r (L _1. c 16.International Shipments i•- Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for only. Date leavi U.S.: W 17.Transporter Ackno I figment o R4 ipt of Materials Transporter 1 Printe Signat Month Day Year O -14 N ^�+ QTra nsporte r 2 Pri n fe d[T-yp-e'd N ime Signature Mo th Day Year t- 18.Discrepancy 1 Be.Discrepancy Indication Space ❑ Quantit y El Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number LL Facib/s Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLJ 1 H 1 41. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except'as noted-in Item 18a Printed/Typed Name r Signature;' Month Day Year EPA Form 8700-22,(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS NAME C L.V 2 ADDRESS dox 352 1-�.ra�Ntso a� I VILLAGE LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE:. TYPE: OR CHEMICAL CHEMICAL wn/1S ��D GO L� COC/�t L 1. b ASOIi.✓L VAS SI ttl. (Give same information for anv additional tanks.on reverse side of card) DATE OF PURCHASE OF EACH: 1. ,S1q 2. 3. 4. DATE OF FIRE DEPARTMENT PERMIT: A7 9 TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS .r I o�TK�To TOWN OF BARNSTABLE �Q o OFFICE OF BAHS9T6HLE, : ' BOARD OF HEALTH �o MAY 367 MAIN STREET Copy I o i639• 4 'F�MAY k' HYANNIS, MASS. 02601 I February 17, 1981 THIRD REQUEST I Manager Hyannisport Club P. O. Box 392 Hyannisport, Ma. If I I Re: Your underground fuel . stor_age tanks located on Marchant Mill Way, Hyannisport Ii Dear Sir: On March 11, and September 30, 1980, you were sent a copy j of the Board of Health Regulation for Underground Fuel I Stor-ag-e -and a card to fill out and return listing information concerning your underground tanks. You have not returned the card nor acknowledged our letter. Town records indicate that you have received' a permit to store fuel underground. Please be advised that if you do not return the enclosed card within five (5) days, steps will be taken to revoke your permit. Appropriate action will then be taken to have your tanks neutralized or removed. You are also reminded that any tank fifteen years of age or older must be tested by the Kent-Moore Pressure Test. An empty tank may be tested by a 5PSI Air Pressure Test. This testing must be done immediately. j The enclosed card must be filled out and returned immediately. i Very truly yours, n M. Kelly irector of Pu is Health f JMK/mm encl. 1 � i s � �. `'. �� t'. .� �, _ e .. 4. ��, "' n � -` ,r, •' R � -,Sr, '_fit, ^�� _ - , �y 4� } " � � rAC.ir � � x R• 14'F � �Z� L �' • • •t'"7 £r ')` - v S' . . � •� , r- _`•� _ � � 1 to � VYY +� • , e- -� � •i-� � ,. .� �.r _ - s . »S .:�. -i•- III -Manager Hyann3sport 'Club � ' q r . rtJ. •Box 392 AJ . ♦` r - .Hyannpert, Maw Al .. � ah. �t. •'°* _ �.-•� '�_� �y,« s s +w '•i ��a- R r �,� a.Fr r 5 r'"" • ,. i- Marchant MS.1�. Way, iyar :sport �� �" -fir �` r� <.. .. z _}- .� .,+aw ��t-- ° A-, ' a�.,� .. • '" V'j! a a -- _ � • 2i � "'"� 't'•,T_ R �t ` �}� _ -� '._ Farr _ - -, t � �� ,� t. � ... ,.V. i •A -. , � 4. Sys• - • � t i ( •+• .. •' � ' , •� • *-S r -s �• `r , Ar 'r,•t. Y• . 4 #.. 'f of-'i fV.R . y , a NAME LOCATION Hyannisport Club P.O. Box 392 Marchant Mill Way Hyannisport, Mass. (N/c) Scudder Ave. Hyannisport, Mass. BOOR & PAGE--DATE' GRANTED, AMOUNT STORED 109/4 June 10', 1974 Under--2,000 gallons gasoline DATE PAID 1974--June 10 MAR 121975 � 37 LIAR MAR TOWN OF BARNSTABLE �.: ; UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS '" ASSESSORS MAP NO. (j}� PARCEL NO.. / � � GJ ADDRESS!?6- 32.0 /:-ZL/7 �� d-in:&vi U(L VILLAGE, NAME:._ /7LG�rt�I�en�r�.. .. �'lyAALA . 7^✓1.G.. CONTACT PERSON here G os 5"6 PHONE NUMBER LOCATION OF TANKS: APACITY: ..TYPE OF FUEL AGE: TYPE: LEAK OR CHEMICAL: DETECTION. �an�eytG✓r� � e � �3�e k �/�'���Gc' �(.�� ��t h n- � 6+ee SYSTEM J'/YT DATE OF PURCHASE OF. EACH: 1. G-w"?N 2. 3. / 4. 5. DATE OF FIRE DEPARTMENT PERMIT: e- 7Y 5--9-37 TESTING CERTIFICATION SUBMITTED: - 3 -. PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. L)) �.✓ `{./ 1 t � � 4 h � 1 Y �+. �, CL.V3 60)3750 (- ,} it,n.n�sao�r CLuI� =(ZV..S..!I�G_...AV ..�._ �1`/�A IS-iOk . M�1��c�n�anL E onTAeT M ARcAAAT Ft LE T t' Stec 1 As tv-\} fw-,!Ovkq� L - _ PCX 3�r,Tcanc�n t MARCNAy-t Aha L l?oL- Z_ r G9 �" He l� M! l'�2T �x✓F /(.. L' Nl��±.�a�r ��� '7 /`J/1 ` lu,,/1' 7 I...•.«uft.. .0—«D ci Sa au a I- TANK TO TEST CAPACITY too �/,�1• L� sew.own •oO °��,�"bW .'*C±O 6 - T..►Nmd.ana...O,r, n..we.r ss•w. crr• -� c.."m u ComP«ry Eevw«rw DW AsIs a-d-M a is Tn Ca...fV F G r} gMro Wi.O TSTi «. wr 6s 5--DETER&MMIN6 TANK CA►ACrM L Our Al(, c FILL-UP FOR TEST Oe r1?vfTJ ,4,i'i• G�`•v2 ��� IsM�wa Gallons �M a Ia Is. QAKar 'POW 6TICK BEFORE AND AMR fACM COMPARTMENT DROP OR EACH METERED DELIVERY QUANTITY /Vp r Tart Dion~ �/ �/ ll ►+oa1a In IW tw*(14 to DE FiMto SPECIAL CONDITIONS AND PROCEDURES TO TEST THIS TANK VAPOR RECOVERY SYSTEM 5w a onvid aCLm aooruala Cn.et Ado•.«d weord f•omdtss A by(26). I wow In 10" C3 NO wmw Mbr In fsnr WMINGrMf I] LM111 rd.q rrrae dlh LVLLT ❑sop E TEMPERATURENOLUME FACTOR(E)TO TEST THIS TANK Is Tow Vfnow?_ CotldtM F P4tglp r TwA F 'I* RodaC on Tram F Elmsasd DwW 1`w I • Ttera�sa+c rsadleg.nra. O(v !d-aft.. 2 L I �t T •f . T N.~ JIM'S PUMP s TANK SERVICE' ptgls pw In rwW of wsP•ar d�ia 3 • > FEATURING KENT•MOORE TESTING EQUIP. rC a ' 0 Or G T /' x m*Mawr in amom Mrs of.*yseAioa f.a waiam area in this rVlr Id um(Is of 17) i..of.sd Pr**Ad Pe F. P.o.901224 JIM CHASE MARWICK MA 02US .arcs amps oar=P 04) Dfpas par•F in low Vai—a,af g P.dtpa "a MMipa(27) CoiMlPcd as A daaa.rl Prow Efrsar Ifq STUFA UTC fry a 7CDFl r� -KT Vows! ARdr4aT® Las w 1EA r'°ttellffis Illm 11 OD GL _!ig Fm W EACH REAOlu6 com how T«rr.dws M Fp Isr nsaf sR Rases dftrb d 9"A rnrs a�"'� a�rir«� K.Frr 1-F Tp„ad 0-p E••F'�_ � Isa Fr F.o� frr raasifp D4I.(Iks Faf a iw;rq r uM ` k1=kl r` ■ ua_.pw fss Iww- - Ma.aa bso d Ers i•Dads&) w rs w.M ur ;z 6"" p Tamaoas- Ofr! tr•a.al I ssd B+afel 4._.wl`) AD�n-•I/(TI taawa.af' p �uSfrr 11 D �iAA>d A-peo .evet F42 l� 0900 PIP 10)S I FI tB .boo �P.d�� , 0 o m ' D .GGa �, 730 f Die OSD6 . 0 6D a o iIi / I / S p TIC d / fiot qo • ol6o 91 o a�bd b40 : fl A D o$D l /9 0 o t. D 3 0 b0 ,+. 0 3b 1f- $ 1 i I � i - .. .. Vf Hu 4 ffs DEPARTMENT OF PUBLIC SAFETY—DIVISION OF FIRE PREVENTION PERMIT 1/7 Date r' TO MAINTAIN AN EXISTING/NEW UNDERGROUND STORAGE FACILITY In accordance with the provisions of 527CMR9.24 this permit to maintain an existing/new underground storage facility is granted to: Location of property: A�AC"AJf &.- J /' Street address Owner of property: CT�.a 'r or7� � Z -// F 1 name of person, firm or corporation Restrictions: Fee Paid:$ A (M.G,L.A, Chapt, 148 Sec. 1 A) Form F.P. 290 , Part a This permit will expire f-/l/19 fZ�__7j 6,,.,.-- d —� Date Sign toe f Head of.Fire Dept. or ap inted des nee (Owner' s Copy .to be posted at the storage facili y with F,P,290 Part 3) FIRE DEPT. FIRE DEPT. STATE USE ONLY CERTIFICATION I D ber Copy to be certified by' local: fire depdttnent&V 7 arid: POSTED AT STORAGE FACILITY D�e .dS� 7� INFORMATIONGENERAL Notification is required by Federal law for all underground tanks that have been 4. pipeline facilities (including gathering lines) regulated under the Natural Gas used to store regulated substances since January 1,1974,that are in the ground as of Pipeline Safety Act of 1968,or the Hazardous Liquid Pipeline Sato\ Act of 1979.or May 8,1986,or that are brought into use after May 8,1986.The information requested which is aninunstate pipeline facilitvregufatcdunder State]a\As: is required by Section 9002of the Resource Conservation and Recovery Act,(RCRA), 5.surface impoundmcnts.pits.ponds,orlagoons: as amended. 6.storm'water or waste tinter collection systems: The primary purpose of this notification program is to locate and evaluate under- 7.flow-through process tanks: ground tanks that store or have stored petroleum or hazardous substances. It is 8.liquid traps orassociated gathering lines dirccil\related to oil or gas production and expected that the information you provide will be based on reasonably available gathering operations: records,or,in the absence of such records,your knowledge.belief.or recollection. 9• storage tanks situated in an underground area (such as a basement, cellar, mineworking,drift,shaft.or tunnel)if trite storage tank is situated upon or above the Who Must Notify? Section 9002 of RCRA, as amended, requires that, unless surface of the Iloor. exempted,owners of underground tanks that store regulated substances must notifc designated State or local agencies of the existence of their tanks.Owner means-- What Substances Are Covered? The notification requirements apple to under- (a) in the case of an underground storage tank in use on November 8. 1984.or ground storage tanks that contain regulated substances.This includes am substance brought into use after that date,any person who owns an underground storage tank defined as hazardous in section 101 (14) of the Comprehensive Emir..........a1 used for the storage,use,or dispensing of regulated substances,and Response.Compensation and Liability Act of 1980(CERCLA).with the exception of (b) in the case of any underground storage tank in use before November 8.1984. those substances regulated as hazardous Neste under Subtitle C of RCRA. It also but no longer in use on that date.any person who owned such tank immediately before includes petroleum.e.g.,crude oil or any fraction thereof which is liquid at standard the discontinuation of its use. conditions of temperature and pressure(60 degrees Fahrenheit and 14.7 pounds per What Tanks Are Included? Underground storage tank is defined as any one or square inch absolute). combination of tanks that(1)is used to contain an accumulation of"regulated sub- Where To Notify? Completed notification forms should be sent to the address stances."and(2)whose volume(including connected underground piping)is Wj or given at the top of this page. more beneath the ground.Some examples are underground tanks storing:1.gasoline. used oil•or diesel fuel,and 2.industrial solvents.pesticides,herbicides or fumigants. When To Notify? 1.0Nners of underground storage tanks in use or that have been i What Tanks Are Excluded? Tanks removed from the ground are not subject to taken out of operation after January I. 1974.but still in the ground.must notifc by I notification.Other tanks excluded from notification are: Mas 8.1986.2.ONncrs who bring underground storage tanks into we after May 9, 1.farm or residential tanks of 1.100 gallons or less capacity used for storing motor fuel 1986,must notify within 10 days of bringing the tanks into use. I for noncommercial purposes: Penalties: Any owner who knowingly fails to notify or submits false information I 2.tanks used forstoring heating oil forconsumptke use on the premises\%here stored: shall be subject to a civil penalty not to exceed S10,000 for each tank for which 3.septic tanks: notification is not given or for which false information is submitted. INSTRUCTIONS Please type or print in ink all items except"signature"in Section V.This form must by completed for Indicate number of each location containing underground storage tanks.If more than 5 tanks are owned at this location, continuation sheets photocopy the reverse side,and staple continuation sheets to this form. attached WNERSHIP• . • • Owner Name(Corporation,Individual,Public Agency,or Other Entity) I (If same as Section 1,mark box here❑) I i �I ytR InT Stb Q:Z C L-L)3 Facility Name or Company Site Identifier,as applicable Street Address Count Street Address or State Road,as applicable City State ZIP Code County a j IVnfA 00657 3C Z-yX- C\Ue Area Code Phone Number City(nearest) State ZIP Code 617 77�5 -060 c 7 Type of Owner (Mark all that apply(0) rlvate or Indicate Mark box here if tank(s) ❑ Current ❑ State or Local Gov't Corporate number of are located on land wtin ❑ ❑ Former ❑ Federal Gov't ❑ Ownership tanks at this © an Indian reservation or (GSA facility I.D.no. uncertain location on other Indian trust lands ) CONTACT • • • Name(If same as Section I,mark box here ❑) Job Title ` Area Code Phone Number c, 17 �o Cr,u e -k v c�v�-� K&1 7 S--S 116 IV.TYPE OF NOTIFICATION ❑ Mark box here only if this is an amended or subsequent notification for this location. CERTIFICATIONV. I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents,and that based on my inquiry of those individuals immediatel responsible for obtaining the information, I believe that the submitted information is true,accurate,and complete. Name and official title of owner or owner's authorized representative Date Signed - I6 �c5iAc + �'Y - g Form F.P. 290 Part 3 Page 7� Owner Name(from Section l)_flyRrinr'S,Gbr � Location(from Section II) MA c44✓1 W,'11 h14y page No. Tank Identification No.(e.g.,ABC-123),or Tank No. Tank No.I Tank No. •Tank N Arbitrarily Assigned Sequential Number(e.g.,1,2,3...) I.Status of Tank (Mark all that apply®) Currently in Use ® �� Temporarily Out of Use Permanently Out of Use Brought into Use after 5/8/86 ] C� 2.Estimated Age(Years) � 3.Estimated Total Capacity(Gallons) 4.Material of Construction (Mark one®) Steel Concrete Fiberglass Reinforced Plastic Unknown. � C� Other,Please Specify 5.Internal Protection (Mark all that apply®) Cathodic Protection U Interior Lining(e.g.,epoxy resins) None Unknown Other,Please Specify 6.External Protection _ (Mark all that apply0). Cathodic Protection Painted(e.g.,asphaltic)Fiberglass Reinforced Plastic Coated None Unknown Other,Please Specify 7.Piping (Mark all that apply®) Bare Steel Galvanized Steel Fiberglass Reinforced Plastic Cathodically Protected o Unknown Other,Please Specify 8.Substance Currently or Last Stored a. Empty in Greatest Quantity by Volume (Mark all that apply M) b. Petroleum Diesel Kerosene Gasoline(including alcohol blends) Used Oil �— Other,Please Specify c. Hazardous Substance Please Indicate Name of Principal CERCLA Substance OR Chemical Abstract Service(CAS)No. Mark box 13 if tank stores a mixture of substances d. Unknown 9.Additional Information(for tanks permanently taken out of service) a. Estimated date last used(mo/yr) b. Estimated quantity of substance remaining (gal.) c. Mark box®if tank was filled with inert material (e.g.,sand,concrete) Page 2 �� �� 'ice iJ � � __ _ � .,� �. � � �� 3 � i Aannijport Clul HYANNIS PORT, MASSACHUSETTS 02647 To: Barnstable Board Of Health From: Hyannisport Club Re : Fuel Tank Tightness Test Please find the enclosed report from a tightness test of the storage tank (#84) located at Marchant Mill Way, Hyannisport , � / v MA. Any questions should be directed to the Golf Course Management Department , to Charles Passios , Supt . at 775-5116. P.T• /'!•f1 TAXK TO TEST CAPAOTY ^ r/r C: n•••,• A..i•J r Tw W..Lar•i.e>,.n .r...r•..�. / G..w Or. y Gro.n.l.yvw.y Ow r....r,I"C.0.o..1 Q C) Cwo.r..w-a TT" . ... ... I..1---omRwwr4 TARO C"ACITY- L 0~ FILL UP FOR TEST ` +��`•°" T..+n...•. r w w nr.••. r R..ory iRcr wow Roo.R rd..raw � r...•�.T to w w 6....r /iR mpfT=8IFORI&AD AMA 9ACM.COMFARTYIXT DROP OR LACK YITTRID DIIIVIRT OL"TITY .Tuf.' Ln T■*two.~. / ( // / ►rr•anl ti 1W 6(y to AS POO SPECIAL mxor 10NS AND PROCEDURES TO TEST THUS TANK _ ,F WPOR RECOVERY SYSTEM s«.v..«s nw.r•...rl.0..&T•.r.w....a r...I is y(261, G �.S N t"U f�� /�,.:.,>� ,r s{ ��=..Y". ❑-+� �r . Now In b■,R INS■~rrr in WA u.+...rR Lryy r.ry b.... d.M LVLLT ,�•L/ {Q••'w R TE)APERATURE/VOLUME FACTOR(a)TO TEST THIS TANK R Tmw vww?= Cowl M_•F Frraia■T■* r F*,o tim a T/w_•r E,a.nw w.o.1• -1 (c(»u2-&u Dyb N 7 In rwqb r(r.poc.d r+� r )iM'S PUMP a TANK SERVICE "' ruTu+u+.c uxr..00ra TT:Twa LQUII. "1 s 1 x r.p. T. I ■e..lb.r.d.spl aw w r..rrr . P.0.901 224 Jw CKW gARwICK WA 02W b o o d . 7 / 7 �s .. o ? Tuft rr.r d..•D.r..*F O."+Y IV he rr V. u.rq.r+d%wL rr .� .� R-va(S?♦ C..P w so♦a—w WwR bow(41 us or iisT Poso mou �sm =308 R is)Li B!10■1/ LLC7 BLAD" I.�.t-d 1 w..... •y�...•�. 1.r• .•...r Cyr - - .w.�r Ir.r rr�.. is ti.c d trn.L d umy.n r,,,.R .r.. •.� Rom....{-1 T►.� .�... rI•u) e...... .•d F.-q W=(U..ti r. M.y t••�■ {�. 1..+- Vim.• Lam 1.1« ■...v.+�.. 1■r I.rout) R....r I �� v� 4rq 1.1 •IY.,-.lRT1 w.�_ L'{,"LJ IT, •r,ql.'- - :.i• `(- "I'^ 7�iD �, Oy! 4a ; yl�ril. 0 �i�� S'', �!`� '.� d /?C { I It ! I , *oaLl . ooiiY 7.Lrr" ' ° �7� 4LJ p ..•r{7 1 ��. 1r Ol�l'i D^rY dn. UI ; . �� IE.� f , ,, •N4� •f10 �. U7� C/r/ 1 U of%,' to1 ,- .. I � • e c. I i , { la tA Ta For Use With KEN T-MOORE J25515 LIQUID VOLUMETRIC LINE LEAK TESTER 1 LOCAnON:-mu A W ry l s PD I' o l F e lG ti ti ►� �s �d>•f" h-!ti= i / St"No er and/or Corn CI Stab Telephone No. i. O 2 OWNER: Nana Address _ Representative Position ,.i Telephone No. 3 OPERATOR: Name Dealer,Mgt. . - or Other Address(It different tan Location) Telephone No. i 4 REASON FOR TEST 1 . _ e C 7. Nr a B TEST REOUESTED BY: (� w Name O Posltbn Order No. Billing Address • SPECIAL INSTRUCTIONS: 7 CONTRACTOR OR COMPANY MAKING TEST MECHANIC(S) NAME pe. t IS A K-M TANK TEST TO BE YES ! MAKE AND TYPE OF ru US y MADE WITH THIS LINE TEST? d- ti <t,,, a NO PUMP OR DISPENSERS 10 WEATHER COVER c - APPROXIMATE TEMPERATURE IN TA •F •C OVER LINES sG Pf BURIAL DEPTH Concrete,Black Top eta 11 IDENTIFY 12 TIME 13 LOG OF"TEST PROCEDURES, 14 PRESSURE 18 VOLUME 18 TEST RESULTS ASCH LINE TESTED (MILITARY) AMBIENT TEMPERATURE, PH OR kPa BURETTE READING WEATHER, ETC. NET BEFO CONCLUSIONS, REPAIRS AND COMMENTS RE AFTER BEFORE AFTER CHANGE b-� bQ obA4441A To 7`4 e( 1� 7Pf7 t-At% 12 /.e f � ,r r �IN Q ca>~T o . a a . ID Lj p a b O D l �� • . � 03 O . l0 3 a o 1t D . - � INe �rf �1 � a a , o o � 13I {d k roo`fo � � ao 0 3 . A2 ocq,a Va `° or Lti ee k1` E COMPLIANCE: CLA . Marine,Gas Stations,Repai.r OWN OF BARNS 2. Printers BARD OF HEAL1"H satisfactory 3. . Auto Body Shops D unsatisfactory- 4. Manufacturers (see"Orders") 5. Retail Stores COMPANY ` A 6. Fuel Suppliers { 7. Miscellaneous ADDRESS - Class. IN=indocrs; OUT=outdoors) ` TIhES AND STORAGE VNl` QUAN I MAJOR MATERIALS Case is Drums AbOveTanks Underground Tanks I UT IN [OUT IN OUTN& g21lons_ &&_erest?_ Fuels: Gasoline, Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) r new motor oil. 1-7 transmission/hydraulic Synthetic Organics: ti degreasers 77, Miscellaneous: U DISPOSAL RECLAMATION REM1,RKS: 1. Sanitary Sewage 2. Water Supply 0 Town Sewer O Public 9 On-site Q Private 3. .Iridoor Floor Drains: YES N0 ,M 0 Holding tank: MDC O Catch basin/Dry well — . OOn-site system 4. Outdoor Surface drains:YES N(114 . 0 Holding• tank: MDC 0 Catch basin/Dry well OOn-site system S. Waste Transporter Licensed? NO jJam off, f Hauler_ _ Qp et i notion .W,1 ,/ i � 4jj �' � tF t et - p`> 4 ,��' ✓ ���� �� ICI pif9660f)v I t' iewed Iiispector Date "TOWN ;OF BARNSTABLE. COMPLIANCE: CLASS;.., 1., Marine,Gas Stations,RFpai.r l "` `'' `0 satisfactory 2•: Printers �B'OA R D OF HEALTH � 3 ,Auto Body Shops ®unsatisfactory- 4. Manufacturers / ( " d ") 5. Retai.I Stores COMPANY �/��Q� �,j y (�A seeOrers 6. Fuel Suppliers ADDRESSJ� ����� / % <� Class: 7. Miscellaneous n/!# QUANTITIES AND STORAGE (IN=indoors; OUT=outdoors) MAJOR MATERIALS Case lots Drums AbdveTanks Undergrouad Tanks IN 1OUT, IIN IOUT IN OUT # eallons Azerest? Fuels: Gasoline, Jet Fuel (A) d.X Diesel, Kerosene, #2 (B) Heavy Oils: 3 waste motor oil (C) new motor oil (C) transmission/hydraulic — / J ; Synthetic Organics: i degreasers Miscellaneous: Ev *I Ii' f Jj� Z/ ry DISPOSAL RECLAMATION REMA KS• 1. Sanitary Sewage 2. Water Supply � `0J .. / OTown Sewer Public _ On-site Private < -0Aj _._._.._._ ,4 3. Indoor Floor Drains: YES NOO 4 Holding tank: MDC Catch basin/Dry well - oOn-site system `i 4. Outdoor Surface drains:YES NO O Holding tank: MDC QCatch basin/Dry well OOn-site system 5. Waste Transporter ftfTTfi f1 Licensed Name of Hauler. nPst;nationMfd6 � f •t' S,rfC /fG. YFS NO 12 23 81 Person(s) Interviewed / Inspector ' Date 1Lor Number. _ -- l�:.te:--- —f- ,- -- - --- i'04 �A sa BARNSTABL.E ,COUNTY :HEALTH DEPARTMENT rt (SUPERIOR COURT HOUSE BARNSTAABLE, MASSACHUSETTS:02630 t) a t PHONE: 362-2511 r ���, 331 DRINKING WATER..LABORAT RY ANALYSISr EMT c� entk, _ yy.w I ' t S< ' 1 t ' C1► Coilec'tQr z - Mailing Address' 'Affiliation T 1- . Ik4 I •�R Lvu:•.: , Time�Bt°Date bit .� d- Fi -♦ 1 _yj .l 1 � 3i •ri ��"� t ] kut_ r 1, a.`.. j rr"'Ys� ltr 'r'I, Telephone ; a � r e ofuPP1Y } ^� Sample Locatiopi'�� `a � qsi H --- -- - 4c,s I � �. ��"5�. r :r� jly 1_ r r.. [�t-i T° y.•'� '.� y... � � Parameter-` s tf«;� :Sam lAeResult Recommen• ' olitorm bactenaC(organisms/100�1J �, -a`=Q `',� .,�# - 0 _ _ � �. x .�.r>a-::tom ,.r,� •.K; ,� ��:-�•: �_;" - ra nf{ � � F1 i - r �r L✓ 2 f _— y -r„t - 7S -�rr• .-,fit` 1r • �J��� E _.: -L'-'.. S '4 Cund�.,ivitY $ sr 500.6 _. Iron E.ppm) x .fYi rrr- 03 l�itr�. t-:�itroentPPm)� ` a t•. - . t e7 aL a y `F 10.0 ------ :. t it Y`. �� '�� ;'- - '• .4. - - tr, . --"- • dater: amPte-m-eers-tj m�e rid ed•`limtts of all above tested parameters , •' .. '- f , Water sample is drinkable but has higher khan average levels of t '� This does not represent-a licaltn:,hazard_buL:futur_e monitoring is recomzn(:nded`(2-3-times per year). +: I,'e v iIl test for Sodium. vi,ater sarnpte is drinkahJc _)uttrriay present aesthetic pioblerns'to users (siaining,•odor ur taste : - I .r LL ' -., 'i •: .. :• do� , '; r p �-ry« _ ter 'sample is of poor qualify and is not'iecommended forhuman consumption T ..._ N- Resamplirg and rctesti7_^ is suggested WL 7. results oftl}` I t i h ^ —t,� x t f f Ii, Z �1, ' �A�rrv. F7' r9� -r-:1 - r� .� E Sf+•1 'a'' 'e- t t,�� �! r ,,t ♦r', ,� r' fi� �+ _ J 1 i —_S-- ;C>Ei ..�� .•"jam .._`� ^::J."'f i_.�.t.tl �tT'�j 1. _ -«FiY• E:,1\1:�.1'.:te7: - t ?i;*1—. -.2e-.. r i� --,a ,j `?Y-'. r ;S• t-ram- ,� r:q, r"`'�-'N�'"� 4t'..� t 7_1 Ivd F i4.{ Y a ' t}1 �• 'ot 5§1 -j` ft r ,.i r r. h .f1 .7�. T S .t •• �".. i , � r ( � V' --�.' 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