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TOXIC-AND HAZARDOU9 MATERIALS REGISTRATION FORM
,Mail To:
NAME OF BUSINESSW
Rut Board of Health
MAILING ADDRESS: -Meds-" &�- je() 14116ANE, 4 Town of Barnstable
TELEPHONE NUMBER: 5DP -77/--P/2--L P.O. Box 534
CONTACT PERSON: .Jr� k 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 qu hies 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 in quantities totalling more than 50 gallons liquid
volume or 25 pounds dry weight. Please put a check beside each product that you store:
Antifreeze (for gasoline or coolant systems) /Drain cleaners
Automatic transmission fluid .d 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
ar 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)
7— 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)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners _
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White Copy-Health Department/ Canary Copy-Business
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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS: nSW nR(A-r- Board of Health
MAILING ADDRESS: RAIQNs _F- ien 4.10mI s Town of Barnstable
\j P.O. Box 534
TELEPHONE NUMBER: '�Rf? -7?/--?/ 2--L
CONTACT PERSON: ' �kkAgeS (,. 4 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 in.quantities totalling more than 50 gallons liquid
volume or 25 pounds dry weight. Please put a check beside each product that you store:
/ Antifreeze (for gasoline or coolant systems) Drain cleaners
,f 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 Photochemicais (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 7 Fertilizers°(if stored outdoors)
Paint & lacquer thinners PCB's
LPaint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes r (including chloroform, formaldehyde,
Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
f
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents
/ Bug and tar removers
Household cleansers, oven cleaners
White Copy- Health Department/ Canary Copy-Business
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TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair
O satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body Shops
O unsatisfactory- 4.Manufacturers
COMPANY do (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
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline,Jet Fuel (A)
Diesel, Kerosene, #2 (B)
Heavy Oils:
waste motor oil (C)
new motor oil (C) wAO
transmission/hydraulic &ac
Synthetic Organics:
degreasers
Miscellaneous:
I
DISPOSAIJREC;LAMATION REMARKS:
1. Sanitary Sewage 2.Water Supply
'Town Sewer &1 ublic
/p On-site OPrivate
d
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 INO
1.
2.
3
rson (s) Interviewed Inspector Date