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1209 PITCHER'S WAY - HAZMAT
z�1�' Number Fee 1043 THE COMMONWEALTH OF MASSACHUSETTS $150.00 Town of Barnstable Board of Health This.is to Certify that Jiffy Lube #412 -------------------------------------------------------------------------------------------------------------------------------- 1209 Pitchers Way, Hyannis, MA ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Is Hereby Granted a License For: Storing or Handling 500 gallons or more of Hazardous Materials. Restrictions: -------------------------------------------------------------------------------------------------------------------------------------------------------------------. This license is granted in conformity with the Statutes and ordinances relating there to, and expires 06/30/2021 unless sooner suspended or revoked. ---------------------------------------- JOHN NORMAN DONALD A.GUADAGNOLI,M.D. 07/01/2020 PAUL J.CANNIFF,D.M.D. THOMAS A.MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable Inspectional Services BM [ABLE oFTME :, (inRN:TnBtE•CENiEtVILIE•COTUR•FYRA'N1S • Public Health Division L639_zo,•Nit?(NIR M:LLS•OB'F.0.Vill%•Y.%Sf 0.0gN5T4&E -'..•` • �, ,4 - MMSTABM 1 Thomas McKean, DirectorMARK „ 16 59. •`� 200 Main Street, Hyannis,MA 02601 NJ r,•l Office: 508-862-4644 Fax: 508-790-6304 V 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 r 4CALL *A late charge of$10 00 will be assessed if payment is not received by July 1st. �00a- L ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? (YES_NO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF • GREATER THAN HOUSEHOLD QUANTITIES(25'G"ALLONS)? YES NO. 4. FULL NAME OF APPLICANT: 1 %11% k n 5. NAME OFESTABLISHMENT'G,,n CAS Cg(y -Aa ��1 'S;4�C� 6. ADDRESS OF ESTABLISHMENT: 11011 pA C tr-5 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: LDS 17 2 c.l u.- L°.k .5,%VC 4 OO %:,./;n -f5c �sbrv�, 8. TELEPHONE NUMBER OF ESTABLISHMENT: ��OB� �Y• l�G(o 9. EMAIL ADDRESS: M �� C.l 10. SOLEOWNER: YES NO IF NO,NAME OF PARTNER: 11. FULL NAME'.,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME 7'�j_PG,M cG r r_t rt _15t LL e— PRESIDENT J G TREASURER a t2W Am 2 CLERK 44 qq ', e i 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICA DATE Q:\Application Forms\Haz Mat Appli Draft 019.docx Number Fee 1043 THE COMMONWEALTH OF MASSACHUSETTS $150.00 Town of Barnstable Board of Health This is to Certify that Jiffy Lube #412 1209 Pitchers Way,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 06/30/2020 unless sooner suspended or revoked. -- ------------------ PAUL J.CANNIFF, D.M.D,CHAIRMAN DONALD A.GUADAGNOLI, M.D. 07/01/2019 JUNICHI SAWAYANAGI THOMAS A. MCKEAN,R.S.,CHO Director of Public Health COO Do IKE ►oNti of Barnstable Office:508-862- 4 • °� J J ub 'c ealth Division Fax:508-790-6306304 BARMSTBLE.�! 200 Main Street• Hyannis, MA 02601 �A 1639.pie TED MA'S TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: Date: ? �61 ao 19 Location/Mailing Address: JIM t , i ®5 CA suaf ` L1 Ui7C062 Contact Name/Phone: SD(� -779- 1966 Inventory Total Amount: — Soo SDS: e -- License#: IDq 3 Tier II : IV Labelina: ye,5 Spill Plan: I Oil/WaterSeparator: No Floor Drains: Emergency Numbers- Storage AreaslTanks: ) Ub V t; Sd e Q 1 APB Oi Emergency/Containment E ui ment: i OdWL Waste Generator ID: i� Waste Product: I Date&Amount of Last Shipment/Frequent-y I A fG Licensed Waste Hauler&Destination: br6Nn Other Waste Disposal Methods: 0"� 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 arld disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids J Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield wash -EE�ZMotor 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 V Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes V 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: (JQ Spill � , , (I n 0(JIS, I Inspector: Facility Representative: �— WHITE COPY-HEALTH DEPARTMENT/CANARY COPY- BUSINESS r, Town of Barnstable Inspectional Services BARNSTABLE CT jHWE� wRNvTt,P:E•CCfiiifil:;L•CO'VR•.ixnHhl= Public Health Division VSTCtint,•Q58YLLE•+:SBWK0.4E 1579-7014 saxNM„srnstE) Thomas McKean, Director I '°ren 039. a`� 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 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 3 Oth). 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 Eg` VST- (�1 *A late charge of$10.00 will be assessed if payment is not received by Jules 3 1. ASSESSOR'S MAP AND PARCEL NO. ' _3 �� a 2. IS THIS A PERMIT RENEWAL? /YES_NO. IF YES, SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS, INDICATE WHETHER BUSINESS HAS • ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)?� YES NO. 4. FULL NAME OF APPLICANT: c��vh ej b✓! J 5. NAME OF ESTABLISHMENT: c 1 L w f/ 1 6. ADDRESS OF ESTABLISHMENT: f AC/5 �I�f,�,�.(i'S 1l y �I,91k n tY) ,M A 0) �V i 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: SUS'Q-ecd�er G�' �c�,��e. ydd �,V�� 8. TELEPHONE NUMBER OF ESTABLISHMENT: -d r" 7 7g^ INC 9. EMAIL ADDRESS: 1 i 94 Ce ��`f�� wvr l d . Cow, 10. SOLEOWNER: YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME __rei44" C fn /` Cot V't rG ctI `I' LL C PRESIDENT `5c c� 13 d a n a. TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT. G DATE C/7 Q:\Applicafion Forms\Haz Mat App Revised 09-10-18.docx Number Fee 1043 THE COMMONWEALTH OF MASSACHUSETTS $150.00 Town of Barnstable Board of Health This is to Certify that Jiffy Lube 1209 Pitchers Way, 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 06/30/2019 unless sooner suspended or revoked. -------------------------------------- PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2018 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health loegulatoryw of B4rnsxable Services t� Richard V. Scah,Director ' � ram, "o Public Health Division BARNSTABLE • dMNSTMIE.ff?REIMLLF.miIRT•NYAHNIS BARNSTABLE. Thomas McKean,Director ; "a< . - 16 9..�a``� 200 Main Street, Hyannis,MA 02601 �77� Office: 508-862-4644 Fax: 508-790-6304 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 X V-S *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO.. 2. IS THIS A PERMIT RENEWAL? r/ YES_NO. IF YES, SHIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF • GREATER THAN HOUSEHOLD QUANTITIES(25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: /.�d 1 H 4��n t� A-/9' rJ !01 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: J U F , t C ke r C�, 8. TELEPHONE NUMBER OF ESTABLISHMENT: g"d g-?7?- r 9. EMAIL ADDRESS: (',d 1"� !e ve �, 6 vo r(d,cot', 10. SOLEOWNER: YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: • NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT L-- DATE QAApplication FormsViAZMAT APP 2017 REVISED.docx JUN 20 2017 PM d2:15 Number Fee 1043 THE COMMONWEALTH OF MASSACHUSETTS $150.00 Town of Barnstable Board of Health This is to Certify that Jiffy Lube 1209 Pitchers Way, 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 06/30/2018 unless sooner suspended or revoked. --------------------------------- PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2017 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health y� In-10 Tow1�, of Unstable Pluro dl K--w q 3 1 C S- Regulatoervices TME r -k 6 a Richard V. Scah,Director Public Health Division pw. BARNSTABLE • �• i•� 8nRN5TA6Lf••:ExtFI:YILL[.CO1UR•HYut:15 • �S'"LE. • Thomas McKean, Director eD w 16 9 za 4" prf 3,t s`� 200 Main Street, Hyannis,MA 02601 �77g x Office: 508-862-4644 �. Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE Wd HAZARDOUS MATERIALS co 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 3 Oth). 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 S _ *A late charge of$10.00 will be assessed if payment is not received by Jules 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? r/ YES_NO. IF YES, SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF • GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: Du"eS Id i 1 I iS 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: a4 P �t,p rS 1i✓a �� �' n i S ; ,1�'1 A OeZ P) 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: -9(�� G'�' u��p, yea Te-s� q)y-e 7 S B as 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: COw,4 10. SOLEOWNER: YES NO IF NO,NAME OF PARTNER: 11. FULL NAME.,HOME ADD . SS,AND TELEPHONE#OF: CORPORATION NAME ati e e PRESIDENT a 4` a TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANTS` DATE Q:\Application Forms\IHAZMAT APP 2017 REVI docx °Ft roy� Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 • BARMA.BR E ` 200 Main Street• Hyannis, MA 02601 n "rECMP'�°`e -:Tip T/ �OXIC AND HAZARDOUS MATERIALS INSPECTION REPORT �u Y/l3 I'f"'l Business Name: : ip V Date: kl io !7 Location/Mailing Address: 12-d>01 ►`r-e-kt.r 4n Contact Name/Phone: I%A- - nit. -77� -I 1043 Cc,+3 Inventory Total Amount: "�"7 w� SIDS: 0v%1 1%4- aGa t"fi+001 m License#: Tier II : 8 Labeling: OK Spill Plan: sQGG Oil/WaterSeparato A Floor Drains: b Emergency Numbers: e5 Storage Areas/Tanks: XLej S 0-A- Emer enc /Containment E ui ment: qe. owe �¢e Waste Generator ID: 1WfiW1Rqq2,31 lWasteProduct: Date&Amount of Last Shipment/Frequency: 3 xg 17 wle c S Licensed Waste Hauler&Destination: S .✓ 7 )•?.e,a_ 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 y Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes � Bug and tar removers Hydraulic fluid (including brake fluid) 1/ 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 V 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, I - hydrochloric acid, other acids) VIOLATIONS: 4&� w5 ,Mop ��l `\c�nh� Ncr� 0 � VL O5k • £Xce%%NJ.e— p O DERS:- ova %A"A-, o k .c a a, k Qw,1 SakJ! c, % owxe.-! I FORMATIO RECOMMENDATIONS: �, o<'be 1��^l Z t'-��e�r.y�.., �a! 0<< vvl 7-14 Q, Inspects 7 Facility Representative: C�•f-c,�.c. ow`�4w�,t.,�vvw\.�l•�avt�� a. �►�vt,_ v\0�-y,�k e�ec•e��able�. WHITE COPY- HEALTH DEPARTMENT/CANARY COO- BUSINESS IKE Tok4 Town of Barnstable Office:508-862-4644 • °� Public Health Division Fax:508-790-6304 • BARMAq .�` 200 Main Street• Hyannis, MA 02601 1 6 79 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT lFD MP'� Business Name: •�1` V �-�b�- Date: Location/Mailing Address: t2-ol e.'�c. ar�►� Contact Name/Phone: tv.w D•Q.w...e_ o o —7 U., —t� InventoryTotal Amount: ^'�1'0O 9&1 MSDS: 0w�1�a.� 54�t� License#: IDS 3 af� Tier Il : Jet, Labeling: ° Spill Plan: c F- -6 es Oil/WaterSeparator: BPS Floor Drains: o Emergency Numbers: Storage Areas/Tanks: 4AkAAlJ4,e �a•kVt-S 1v-, 1payc.rwhA��- 44ca,yc� .�0�/S Emergency/Containment E ui ment: Waste Generator ID: `1$1 S`) 231 Waste Product: Date&Amount of Last Shipment/Frequency: a(311 b 0 52.,9 a( A.- t-2 w 1c S Licensed Waste Hauler&Destination: � � K�e�-h ca>r.ska•.. Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS 0 INS I (, a� - s NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, p,� 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) s=" 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, e hydrochloric acid, other acids) VIOLATIONS: ✓ e�a�� v• 9 11 ow b4 ycan��h1mo<— u�o� e}�l-cw� 5 �w caulk coovti.-vw VoA-AN c. ,1, ctv ,no cs O ERS: -,QM VCtk 4 yQs-6—,,, Rge (Za vl ,11.E a, ( oo\ Jr k.xte— SaAv �.eA , INFORMATION/ EC MMENDATIONS: Qn mAn,��� �� z,�lil_lonl� wt ,� Inspector'o —°`v-c"��t. �mwK.S�A•�CS �a�.1��00►�, v1� abo,� 5V ity RJpresent v qtt,5X SS � ® WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Number Fee 1043 THE COMMONWEALTH OF MASSACHUSETTS $150.00 Town of Barnstable Board of Health w , This is to Certify that Jiffy Lube 1209 Pitchers Way, 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 -TOW/Cr Town of Barnstable Zy6a�- • Regulatory Services ti Richard V. Scali,Director MAR& � ` Public Health Division BARNSTABL 16j9 ,0� �u-a"a°��ue�ws"ainnsu Thomas McKean,Director 1639-2014 377� 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Pd 6g�1/ ax: 508-790-6304 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— 1st—JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 ❑l c CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ,l�l ►I v • A late charge of$10.00 will be assessed if payment is not received by July 1st. ASSESSORS MAP AND PARCEL NO. DATE FULL NA OF APPLICANT: �a h BS ME W I I NAME OF ESTABLISHMENT: 51'f-(`� L. v►�8 �!- �.� ADDRESS OF ESTABLISHMENT: Wp q &Ck' P s wA� 60"Mit's , A X w a l MAILING ADDRESS(IF DIFFERENT): /QS' e0 eE K Cf. SUi fr, To Z'rv;a s o&� TELEPHONE NUMBER OF ESTABLISHMENT: SOP ` 77X- /90U EMAIL ADDRESS: l.ON1 � P, c�l �✓orld,Cf/!n, SOLE OWNER: YES NO IF NO,NAME OF PARTNER: FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME Park „cI ytf'AQ4✓& she,-Vo r AC. PRESIDENT A" p P, TREASURER CLERK • IF PREPARED BY OUTSIDE PARTY: SIGNATURE OF APPLICANT Name: Company Address Telephone#: loop Email: QAApplication Forms\HAZZAPP Revl6.docx Page 1 of 2 Number Fee 1043 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that Jiffy Lube 1209 Pitchers Way, 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 i Aug 14 15 08:23a Jiffy Lube Hyannis 5087780533 p.1 Town of Barnstable a OFZNE) Regulatory Services .� o� Richard V. Scali Director To Vl1 i`s !C7. °" MASS. E' ' Public Health Division - k`AS r yQ MASS. g 1639- Thomas McKean, Director ;.y3 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-740�6'304 Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO. " DATE 711,r APPLICATION FOR PERNHT TO STORE AND/OR UTILIZE MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT ':yc'i, PS NAME OF ESTABLISHMENT ,M L 12 ADDRESS OF ESTABLISHMENT l A a 4 P,ic ti Pis I,✓a y #y a o,hi S , Ah a)fv TELEPHONE NUMBER n$- Ilk— I Y 6C SOLE OWNER: YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTN7ERS: IF APPLICANT IS A CORPORATION: FEDERAL,IDENTIFICATION NO. 19--as�0101 STATE OF LNCORPORATION / 9,SS a-C4 uSe4l FULL NAME AND HOME ADDRESS OF: PRESIDENT LaYry Aa,ic e, 10S PtrkOrC4 5-vj"4✓ TRERxSURER -3�d H 14 West e t, OS" D k r S _'�c taa -rv,�Al SIGNATURE OF APPLICANT " • RESTRICTIONS: HOME ADDRESS HOME TELEPHONE# PTLAZAPP.DOC 4 r Town of Barnstable Office: 508-862-4644 a Regulatory Services Department Fax: 508-790-6304 nnrnse Public Health Division v Mnss. Thomas A.McKean,CHO MAC 6 200 Main Street, Hyannis, MA 02601 Payment Receipt ,Hazardous Materials Payment received: $100.00 (Check) on 8/20/2015 (Check number: 391530 Check amount: $100.00 Name on check: Heartland Automotive Services ;Business: Jiffy Lube #412 Owner: KC HYANNIS REALTY LLC ;Address: 1209 PITCHER'S WAY, Hyannis ' 4 • IKE►ok� Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 a""; B% 200 Main Street• Hyannis, MA 02601 ,6M a MAC ,0 _TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT QED Business Name: --�`�� o Date: O -? /� Location/Mailing Addres : 1 zo c. .rs a ai v Contact Name/Phone: <e t•[- I -oAo kv - Sfocc..-A4 Sot -772>-Ig64 Inventory Total Amount.n.'7bvo &� i MSDS: ��2 License#: �`� 1 � `' G�k 4 1 '0 Tier II Labelina: e,o Spill Plan: e5 Oil/WaterSeparator: . %,-J o D4as; o Emer erJ Numbers: Yes Storage Areas/Tank a� to \s �l.�0 a o��fi 4 l -foSd �t Igo 4\Pc��c� Emergency/Containment Equipment: � Waste Generator ID: ® 1 Waste Product: O �h_g��-.�_� Date&Amount of Last Shipment/Frequency: weeAe-,s Licensed Waste Hauler&Destination: ;SaAA-A In. Other Waste Disposal Methods: c&%w <-Da- . tS w/lb D 2A-P.-0\\Avk\.1 w kaCfAlt,<' 50\vk-iow 7 W a-grk� k 5 p o�t a-�1- w .i LIST OF TOXIC AND HAZARDOUS MATERIALS ',c` 1 (v O .nil 4 c f c`n4�. - �vl �k�}�vl�s 5,-,ee— NOTE: Under the provisions of Ch. 111, Section 31, of the G neral Laws�Sf MA, hazardous 4terlal use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. yAntifreeze 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 V Miscellaneous petroleum products: Road salts grease, lubricants, gear oil �\ Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries A,-3 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: I p L���k 2'X��O�^f�-� O ERS: e-w�W A��tf v6 e�� S �G�� w�� , O 4vDl L&J-i INFORMATION/RECOMMENDATIONS: Av tA& A- �� oc�C-S o oks +a C VAa,.4- U y 1 -I-awVet, . CMh e fA-. kc4LIJA vL pector:— I L.c�v� �-P� Facility Representative: 1KCZ WHITE COPY- HEALTH DEPARTMENT/CANARY COPY-BUSINESS _. i °t INE Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 • BARMS�LE. • 200 Main Street• Hyannis, MA 02601 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: Date: �� ! Location/Mailing Addre s: t2O RGx-,r� W-A-a . )t--V%K I s Contact Name/Phone: <.e J,w bgoLA-1 o -start r/ ,c-, fie,`t,- XSfr,c} ^t 4 l �5t&c4.- 5768--7-78_ r 'drat-io Z. -0-73$ Inventory Total Amount: ti�°tea MSDS: e License#: 164 3 Tier II : Qote"wk'n.\ Mote!o�� ' Labeling qoo _ Spill Plan: Yjz s Oil/WaterSeparator: OlkN Floor Drains: No Emergency Numbers: ma's I Storage Areas/Tanks: 0 J& �,w „ 4h 16=t A W,.1: c 4-I o o3"-K) n,lAN te o a 0 ) Emer enc /Containment E ui ment: ,�l ,,,,. lco t a e, Waste Generator ID: M D 99 18ri q2t3 \(vasieproduct: Date&Amount of Last Shipment/Frequency: 711714 l Yo q X-1 Licensed Waste Hauler&Destination: S2Fe��/ K/�2vt, �a K s+bK '►�� i V�p�[/g bZgc,G2 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, 1 Y q it�3 storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids v —Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield wash ZMotor 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' MA LC .6A INFORMATION/RECOMMENDATIONS:O ICJ,J1 ao - :�y t 64JI&4r —I 1 w l h o o,1 1 Inspector: Facility Representative: WHITE COPY- HEALTH DEPARTMENT/CANARY COPY- BUSINESS Date:/Z I If 1 /3 TOWN OF BARN STAB TOXIC AND HAZARDOUS MATERIALSii�����FORM NAME OF BUSINESS: BUSINESS LOCATION: 1201 INVENTORY MAILING ADDRESS: . Saw o__ TOTAL AMOUNT- TELEPHONE NUMBER: Sob -778 -196 ", 76 00o 1/oktg CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: We& cel/ 78/-o?S2--o738 MSDS ON SITE? TYPE OF BUSINESS: Redo r�ta,,1,�.cn�t,veG� �e5 INFORMATION / RECOMMENDATIONS: ,�,'��1,,� e,� lri ititvc�voc Firee,District: oM_ ` u. Slb�12- IKs ,ovt,, 1 ai,�,Tievt S J?S' `7 ✓1 I IS I k64 y'—%,l k;N-ve- 1 oW -re.Q f&-,—el a ' Wct -f" n Z A, I"�� yr -IomYs ej-ea L o '�- e +g K �w►'wc- s4tucG,�e- c,7���i o� ZxtaC�� Waste MAN Last shipment of hazardous waste: 1 z wk-s Name of Hauler: � '�-�+ leex� Destination: Se" K6 arish K_ Waste Product: w&gee, o% ( �4vt.+-(-ce.e� Licensed?(!5 Pio 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 s Antifreeze (for rgaoline or coolant systems) Miscellaneous Corrosive U NEWz/aSED 360 Cesspool cleaners j Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts(Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides 6�60 o NEWy3/o Cdi USED l9s0 (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, IPhotochemicals (Developer) D lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine 3� 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 k,4t I.4 e) ✓W o- .0► Laundry soil &stain removers t (including bleach) �74te�O►ZSr�-2 o�(�it c 1��-' Spot removers&cleaning fluids _ (dry cleaners) 60b e c� -{'� �PC►R{{ Other cleaning solvents II Bug and tar removers y P, I �a 1 1 lol,�0 k�' 0 I2Vl ptd H a Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials l 1 Number Fee 1043 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that Jiffy Lube 1209 Pitchers Way, Hyannis, MA i -\Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDO S MATERIALS. ------------------------------------------------------------------------------------------------------------------------------- --------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relay g there to,and and expires 6/15/2015 unless sooner suspended or revoked ---------------------------------------- WAYNE MILLER,M.D.,CHA1RMAN PAUL J.CANNIFF,D.M. 6/30/2014 JUNICHI SAWAYANA THOMAS A.MCKEI , R.S.,CHO Director of Publi Health Number Fee 1043 THE COMMONWEALTH OF MASSACHUSETTS $100.00 Town of Barnstable Board of Health This is to Certify that Jiffy Lube 1209 Pitchers Way, Hyannis,MA 02601 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. 6/30/2013 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable of,HE Regulatory Services Thomas F. Geiier,DirpdDr Thom s McXean,.Director 200 gain Strztt, Hyannis, MA 02601 Fes: 508-790-6304 O±Eca: 50848 464A _ App icaiion Fee: $100.00 - ASSESSORS NSAP AlMD PARCEL N O. �PPLICATIO�t FOR PER��IT TO STORE AND/OR Z .177 mnRE THAN 111 GAILnNq Ow 1�A7,ARD®US MATERIALS F-IILI.,NAME OF APPLICA�I'T VA SE OF ESTA3T LSEM NT ADDRESS OF ESTABLISSIY. l�q-T TELEPHONE N-OMBEB. SOLE OWNE_.R: YES *NO R APPIJCA N IS PARTP�'TULL NAME AND HoNa ADDRESS OF ALL PARTNERS: EF APPLICANT IS A CORPORATION: FE Il3.AL IDENTMCATEON NO. STATE OF JN CORPORATEON ` z F�(TI1L NAi O S� OF. PRESIDENT CLERK / SIGNA' UAE OF * T EOME DRESS \' i I �3z�odwp/q I I ,1 1 MATr,-INREQUESTS Please mail the completed application form to the address below. In addition, please include the :;Z�ed fee amount. Make check payable to: Town of Barnstable. Our Mailing address is: Town of Barnstable Public Health Division 200 Maim Street Hyannis, MA 02601 FOR FAXED REQUESTS Ou r fa,number is (6d�) 79{1-b3d4. Please fax a completed application fo= In addition, you nust mail the required fee amount (see fees at bottom of this page). Please make the check-payable to: Town of Bar table. The check must be mailed to the address listed. above. For further assistance on any item above, call (508). 862-4544 . I i jI i j Number Fee 1043 THE COMMONWEALTH OF MASSACHUSETTS $1oo.00 Town of Barnstable Board of Health This is to Certify that Jiffy Lube 1209 Pitchers Way, Hyannis,MA 02601 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 6/30/2011 unless sooner suspended or revoked. WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 6/30/2010 JUNICHI SAWAYANAGI THOMAS A..MCKEAN,R.S.,CHO Director of Public Health ur f Town of Barnstable °piHE T°� Regulatory Services ti Thomas F. Geiler, Director • BARNSTABLE. MASS. Public Health Division t639. �0 ATfDMP�A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO. -Z�3 /26 DATE 6 -z q — /D APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN 111 GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT CAP e- Co Cl , e4 . .I,cJC• NAME OF ESTABLISHMENT J, Fy 4C.4c ADDRESS OF ESTABLISHMENT /zoI 19.1-e4en.s W.4!(, .02r.01 TELEPHONE NUMBER 509L- ? � .SOLE OWNER: ✓YES NO IF APPLICANT IS A.PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. OY- -3 Ae 4 7 7 q 1 STATE OF INCORPORATION /7A s Sr4 e ktrs e J`/s FULL NAME AND HOME ADDRESS OF: PRESIDENT jot- 1` eA. e,�deZ /6 �n,�,.e�(! �.tiir� Cr. Cvckeysvt�$ /9J '�OjD TREASURER.. /(eAl /7-eo,,eA1d e Z C I •, CLERK 2- • SIGNATURE OF APPLI ANT RESTRICTIONS: HOME ADDRESS 55Ar-.e 4s A6ove HOME TELEPHONE# ql()- k 53- (.2!/ Haz.dacA%-P!q f • EXIMIT A Spill Contingency Plan 1. Evacuate the immediate area,if necessary. 2. Shut off valves,pumps,and electrical equipment as appropriate. 3. Remove or restrict any potential ignition source from the area if the material is flammable. 4. Cover or dike all existing floor drains,sumps,and storm drains if not already covered 5. Contain the spill by use of absorbent socks/booms,then apply appropriate absorbent material or additional absorbent socks/booms. Contact spill response firms in Appendix E,if necessary,to assist in these activities. 6. Remove all absorbed material or contained liquid and package in DOT approved container. Used absorbent materials should be packaged separately from liquids. 7. Label all containers with the type of waste and the start date of accumulation. 8. Notify the appropriate agencies and corporate contacts as prescribed in Section N 9. Once the spill has been controlled and materials collected and secured,inspect the area for cleanliness and decontaminate all equipment used in the clean up. 10. Replace all used materials and ensure all response equipment is in good working condition. 11. Manage and dispose of collected absorbents and liquid in accordance with Federal and State environmental regulations. 12. For any spill greater than the reportable quantity(see Section IV)or 25 gallons, whichever is less,this plan shall be implemented and proper records of action shall be kept on-site as prescribed in Section DC 13. Spill clean up equipment is located in the lower bay of the store. 14. The following is a list of the spill equipment on site: a. Absorbent spill pads,granular absorbent, socks,and/or booms(spill kit) will be purchased b. An adequate amount of personal protective equipment c. First aid kit in the employees room. - d. Eye wash stations in the upper&lower bays • e. Fire extinguishers in the lower&upper bay 22 • IE Mrr H Emergency Services Local Fire Department Telephone Number: 911 or 508-775-1300 Local Police Department Telephone Number: 911 Local Ambulance Service Telephone Number: 911 National Response Center Telephone Number. 1-800-424-8802 List any other emergency service numbers below: NAME TELEPHONE NUMBER Advanced Liquid Recycling 1-800-582-5906 SA M-C-•t K(eeN: t-koo -&3?- 5 Y70 203-238-6771 1-4'ro,- rg Garner Environmental 1-800-442-7637 • CURA Emergency Services 1-800-579-2872 MA DEP 24-hour Reporting 1-888-304-1133 EPA Region I 617-565-3420 Cape Cod Hospital 508-771-1800 Corporate Contact: Joe Menendez,President (410)453-6711 • 31 Number Fee 1043 THE COMMONWEALTH OF MASSACHUSETTS . $1oo.00 Town of Barnstable -Board of Health This is to Certify that Jiffy Lube 1209 Pitchers Way, Hyannis,MA 02601 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 6/30/2010 unless sooner suspended or revoked. WAYNE MILLER, M.D.,CHAIRMAN PAUL J.CANNIFF, D.M.D. 6/30/2009 JUNICHI SAWAYANAGI THOMAS A. MCKEAN,R.S.,CHO Director of Public Health I Town of Barnstable Barnstable 01.1HET Regulatory Services Department o t�,ne�ica ta-�, • B.uursrAf m Public Health Division . 9�A MASI& 200 Main Street,Hyannis NIA 02601 m 2007 Office: 508-862A644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO. L(. DATE (o ' •?x - O q A.PP1 C;ATION"FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN III GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT Cof - Co CC ye�tvn4, lwC NAME OF ESTABLISILVIENT ,,,,f, �Fy Gt�iQ� ADDRESS OF ESTABLISHMENT 4101 Pi re kegj 444 ,U' A*• _VA60 J • TELEPHONE NUMBER - 7 7 - Sob � SOLE OIVNER:. YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS O s ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. Oc( 3,2 ?7 STATE OF INCORPORATION /'1*.FSA c Cute ttz. FULL.NAME AND HOME ADDRESS OF: PRESIDENT jot_ /'?0A-,eNc1et-- A. Cr A(030 TREASURER /IeAteN e Z �• CLERK /!c�u /'l even.6 Z " " /` 14 SIGiYATURE PPLI.C�AN/T. • RESTRICTIONS: HOME ADDRESS fq te e, iE d .r4 4o v-e- HOME TELEPHONE# ke® - k S 3 -6 7/I QA\ IlzmatlFlaz Mat Application2008.DOC • EXHIBIT A Spill Contingency Plan 1. Evacuate the immediate area,if necessary. 2. Shut off valves,pumps,and electrical equipment as appropriate. 3. Remove or restrict any potential ignition source from the area if the material is flammable. 4. Cover or dike all existing floor drains,sumps,and storm drains if not already covered. 5. Contain the spill by use of absorbent socks/booms,then apply appropriate absorbent material or additional absorbent socks/booms. Contact spill response firms in Appendix E,if necessary,to assist in these activities. 6. Remove all absorbed material or contained liquid and package in DOT approved container. Used absorbent materials should be packaged separately from liquids. 7. Label all containers with the type of waste and the start date of accumulation. S. Notify the appropriate agencies and corporate contacts as prescribed in Section 9. Once the spill has been controlled and materials collected and secured,inspect the area for cleanliness and decontaminate all equipment used in the clean up. 10. Replace all used materials and ensure all response equipment is in good working condition. 11. Manage and dispose of collected absorbents and liquid in accordance with Federal and State environmental regulations. 12. For any spill greater than the reportable quantity(see Section IV)or 25 gallons, whichever is less,this plan shall be implemented and proper records of action shall be kept on-site as prescribed in Section IX. 13. Spill clean up equipment is located in the lower bay of the store. 14. The following is a list of the spill equipment on site: a. Absorbent spill pads,granular absorbent,socks,and/or booms(spill kit) will be purchased b. An adequate amount of personal protective equipment C. First aid kit in the employees room. d Eye wash stations in the upper&lower bays e. Fire extinguishers in the lower&upper bay 22 • EXH Mff H Emergency Services Local Fire Department Telephone Number: 911 or 508-775-1300 Local Police Department Telephone Number. 911 Local Ambulance Service Telephone Number: 911 National Response Center Telephone Number: 1-800-424-8802 List any other emergency service numbers below: NAME TELEPHONE NUMBER Advanced Liquid Recycling 1-800-582-5906 SAMC-4 K(QeN; i-800 -&3 7- 5Y?O 203-238-6771 Garner Environmental 1-800-442-7637 CURA Emergency Services 1-800-579-2872 • MA DEP 24-hour Reporting 1-888-304-1133 EPA Region I 617-565-3420 Cape Cod Hospital 508-771-1800 Corporate Contact: Joe Menendez,President (410)453-6711 • 31 TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER AND INSTALLER INFORMATION ADDRESS- i MAP NO. '7 3 PARCEL NO.- OWNER NAME: �� r ��/ .1NG��R;)d f-s�f7 -�/fj/ ` '/�C VILLAGE: INSTALLATION DATE: 7 - ,((a BY: ADDRESS- 'r ' CERT. NO. TANK INFORMATION LOCATION OF TANK: • CAPACITY TYPE AGE FUEL/CHEMICAL TESTING CERTIFICATION C ] PASS C ] FAIL DATE LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION CJ(] YES C ] NO DATE TO BE REMOVED FIRE DEPT. PERMIT ISSUED `` C ] YES C ] NO DATE CUNSERVAIION C ] CHECK IF N/A DATE BOARD OF HEALTH TAG NO. ff, ]C ]C ]C I DATE PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD r CORPORATE OFFICES: 135 Wood Road, Braintree, MA 02184(617)848-4950 ' RETAIL LOCATION:504 Quincy Avenue, Braintree, MA 02184 (617)843-0110 5 Y.0 00 I z ooD I r--7�71 3 h e 2-s wA l , Jay a-N,vi,S I� or�e ✓.GLL�1L �, � � v a• 7lII2T1EL i (J (41A 337 MUN=1 =r RC,GISTRATION j ''.Y z:.11S.hi��CZ601(11 Lfl -1 m BARNSTABLE APRIL ! , = - - Q_ (Cary or Town) !Late) li Tais is�to..ccstif}' t Karote, Inc. d-b-a Jiffi-Lubz has, in accordance with the urcmisio�srof`Caaat�r 348, Section 13,'of the uer._ral Laws, flied mrith a:_ a e_.-ti.ucat_ of regi-•:.ation s_tzing forth that �.� is the holder of �_- Januarv_•�14' co 1986 for the la%- ul•ise of the buil.:in^�s or.o:r.:s StrU• �, } cturc}s)situated or to b_-ruated At -1209 Pitchers lwa ncr Kerry Drive Hyannis,Massi-A -i"Rt 2 CAP Tctsf--nacityin¢allows: 10,000 Contai=.- Uno_rgrounda-. �n Kind of fluid to bestorett Oil 4 wast vil Town Clerk Abov_grount3 •6,000 gal oil . :4;-000 gal wast BA RNSTABLE • rratuze wad offimal Title) Not=A eertMcnte of rc—..t=onn must be filed on or!?-fore April 3Qih of each tZ.-u???�_iTION '1T?T�• rn*tc�t--T,--Ar,. of ahraiiriniiittl ; .y J -4 L - DEPARTMENT-OF PUBL1 SAFETY.—DIVISION OF FIRE PREVENTION �.I �'�►.: a 1010•COMMONWEI,LTH AVENUE. "BOSTON ' aRarngtah a 29 (City or Town) (Dateti� - •td z�3 In accordance With`the provisions of Chapter 14S of the General Latcs, a license is hereby grated to use the land herein described fsr the la«ful use of the building.... or other structure.... which isiare or is/are to be situated thereon,` Y and as described on the plot plan filed %6th the application for this license. Pitehe.i:'.s...Way...............................................Dearest cross street .....Ke.r-z•ywood...Dri.V.e..: ::_._...•.•....... ih A.ocatl6D Oi 1"U -........ ... (St e b Fu bpr s �q ". Owner of land ....krq.t...I.Dc....2 la...�t.1.�.J.-.LUtie.....4dd>;ess 227....East..Main••Streat,...Avonr ,,--P,a�---b2321 t Dumber of buildings or other structures to which this license applies .....One............................................... Lubr.i.catinn...facil a.t ........................................................... Occupancy or use of such buildings ..., y.....•• - underground 1.Q,.000..An...3...tapks." Total capacity of tams in gallons:—Aboveground.......:.............::.........:........... ........." (1 4,000 gallon oil ti r- .... Kind of fluid to be stored iu tanks ........................................................................................ _. 1.... ...0"�6 gallon waste oi,13 Restriction_—If any; SeE...i"•eye.rse.•Si• .............................................. 00(r..9 a.t.l.a.n.----IT.;Y_...... —p .... .. r �Sirnk of lire slur autbonty �_ TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER AND INSTALLER INFORMATION ADDRESS: MAP NO. PARCEL NO. OWNER NAME: VILLAGE: �� r' IN INSTALLATION DATE: BY: ADDRESS: CERT. NO. y' TANK INFORMATION LOCATION OF TANK: CAPACITY TYPE AGE FUEL/CHEMICAL TESTING CERTIFICATION C I PASS C I FAIL DATE LEAK DETECTION C I CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION EXI YES C 7 NO DATE TO BE REMOVED FIRE DEPT. PERMIT ISSUED C ] YES C I NO DATE CUNSERVAT13N C I CHECK IF N/A DATE BOARD OF HEALTH TAG NO. [ ;, 1[ ]C ]C ]C ] DATE l PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD JOE MENENDEZ VICE PRESIDENT OPERATIONS I A LUBE 495 COMPANY - JIFFY LUBE CORPORATE OFFICES 135 WOOD ROAD BRAINTREE,_MA 02184 1617) 848-4950 TOWN OF BAR NSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS v NAME I PZ) L Q d f C/n k AR `fi cd / H Y k A M,8 -La i"L(0 Ke.r-,-y w� bp—, ' ADDRESS _ma c.► 6 L jc: 6 e a q w�Y VILLAGE H V A IVa lC, LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE: OR CHEMICAL �c 11,£2 GL,4 r -rZ A4 5AcfaT 7-0 4©aa GA1 © IL SIFE t\ S I Rvc,T�R Y4� DEAR,� _ ��[� a �:A I c►�RS't� of 1 CaX0 c fZ ' c�i L (Give same information for any additional tanks on reverse side of card) DATE OF PURCHASE OF EACH: 1. 2. 3. 4. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS TOWN OF BARNSTABLE UNDERG UND FUEL AND CHEMICAL STORAGE SYSTEMS J i Q NAME FF� LuFb� G ,ci Lv� M. 12V fi KE¢Q wc�C PGt-• � �� � � VILLAGE -- ADDRESS + j�vet.cS �1' 3�► 2}3-1Zb LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE: OR CHEMICAL ��pea„( ftA.&. Dp at. dL� Aa�i►� r�0�A- ►�1t ll:NA AT TO t� Aw (Give same information for any additional tanks on reverse side of card) 3. 4. DATE OF PURCHASE OF EACH: 2' y DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: I PASSED DID NOT PASS � '[a Ga.t t'atil t�{�Q.o 7170i'mC o 2 DaK�� � ,rw� c cve�nYt y�� r Kear 7b--*j A P P R O V E D ga;as Is Conservation Commiaaion 3- APPROVED �s gnea Dat• TAW OF 8AR EALIN Date ��c _BARN r �/ .a General Contractor Desi 1 Co.9n Build ' r uction Management �bQ ROBERT G.PUDDICOMBE ESTIMATOR 227 EAST MAIN ST., AVON, MA 02322• (617) 584-8922 TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS NAME HI Y Loop G/r3 T W4 • b4t a I4-At-40) Lor ra tZ(. 22Y�v a�{fle ADDRESS 01-4 p« +azS VILLAGE t4 1`41 4�F OeveLomrLuoT # ".-Aft owr OF Zia/►tie LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE: OR CHEMICAL Fib f tZc�T-cl� A D.�l�ct�.1'� 1z5 -� c� yu.. �DV ei��a•�.. tj nab 4ch-6 )wen% !IL � h (Give same information for any additional tanks on reverse side of card) DATE OF PURCHASE OF EACH: 1. 2. 3. 4. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS I nthm/ G[Z gm"tJw-d"v MWv�T WGt 4Tior�rl 1RPPo eD 6'K 3VW4.3 r . r/u—/-c.. A P P R O V E D APPROVED astable Conservation Commission BOARD OF HEALTH a" Y ` _ TOWN OF 13ARNSTA13LE igned Date Date 8 ow,� J �/r..�✓cc T Tu l9 �"/w 1 /6Ggn J K .`. II *INC lo` �,Ild7li '�9'241t�GZt,�' o � DAD11771HL i pp 1639. \ �• OM0 C // �j 367 MainSlreel, Jd yunnie, //lam. 02601 NOTICE OF HEARING KAROT INC. , d/b/a JIFFY LUBE, c/o JSP Inc. , Robert Puddicombe has made application to store 10,000 gallons of oil and waste oil in three (3) underground tanks (4,000 gallons of oil in one tank, 2,000 gallons of oil in one tank and 4,000 gallons of waste oil in one tank) on property �oHned by Karot Inc. and located at the corner of Pitchers Way and Kerrywood Drive (Assessors Map #273-126), Hyannis Ma. Said tanks to be used in conjunction with an automotive lubrication facility. A public hearing on this application will be held in the Town Office Building, 367 Main Street, Hyannis, Ma. on Thursday, January 2, 1986 at 10:00 a.m. Jeffrey D. Wilson John C. KLimm Martin J. Flynn Board of Selectmen Town of Barnstable Legal Ad - BArnstable Patriot 12/18/85 PLEASE BILL LEGAL AD TO: The proposed location of these tanks is right in Robert Puddicombe the middle of a critical zone of contribution to JSP Inc. public supply wells. Tanks must be double-walled 227 East Main Street fiberglass with a hydrostatic pressure tank Avon, Ma. 02322 monitor with an electronic inventory and leak detection control panel. 7' 7- i -• -_. -= ., .. .,._ ry ^-...• •. -+,i*it•,;�`w-t _ .'�.x.. � _tb.. . .N-. Y .. ,-.'.w:. "r*�r:,y�tti ' Ti. ..+.. �: TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER AND INSTALLER INFORMATION ADDRESS: fJ?do/MAP NO. PARCEL NO. i OWNER NAME: 1 `/>3 Incr`d /� �if i.f C��.�* VILLAGE: 7 t YARIVIIIS f INSTALLATION DATE: 2- X6 BY: _� / J'ive ADDRESS: ' ?7 t',7 7 �r� �°J 5 r�% /Iv.��, t'`'A >�3 Z- CERT. NO. TANK 'INFORMATION LOCATION OF TANK: r G/o,, { CAPACITY 25 Ob TYPE SI ( I�.��1 ru'ffAGE FUEL/CHEMICAL TESTING CERTIFICATION [—I PASS C ] FAIL DATE LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND / 60 +EI ZONE OF CONTRIBUTION [XI YES C ] NO DATE TO BE REMOVED C/ FIRE DEPT. PERMIT .ISSUED C - ] YES '- C ] NO DATE CUNSERVATION C ] CHECK IF N/A DATE �}BOARD OF HEALTH TAG NO. C ]C ]C ]C ] DATE 9/Wru--, 11�A�L, PLEASE'PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD Cp ,._., s _ TOWN OF f3ARNSTAE3LE COMPLIANCB:� CLASS; 1. Marine,Gas Stations,REpair 4 satisfactory 2. Printers ffMR OF HEALTH j� 3. (luto Body Shops p '°O unsatisfactory- 4. lanufacturers L% lL-. �� (see"Orders") S. Retail Stores COMPANY �_ t1 6. fuel Suppliers ADDRESS / l �r� 1VA,��.• Class: 7.. Miscellaneous QUANTITIES AND STORAGE (IN-Indoors; OUT=outdoor. Case-lots Drums AbOveTanks Undetgro[md Tanks MAJOR FIATERIALS • HL )1 ¢eIIons &M [A!" Fuels: Y • Gasoline, Jet fuel (A) Diesel, Kerosene, 12 (B) Heavy Oils: Q to .motor oil (C) �ea mot.o oil (C) 10� 4 tra'an ss" on/hydraulic '-Synthetic Organics: degreasers •Miscellaneous: C AP UW K . a 15 , q_0 L=L= DISPOSAL/RECLAMATION 11UV.RKS: /'qC)36 /f e OIL IN iz (fir 1. Sanitary Sewage 2. Water Supply �t - n ` 0- Town Sewer 0�Public /-� !"1 �J ��_� '()/� a On-site � 0 � / � / �.Tm� Private 3. Indoor floor Drains: YES NO ��,V � Q Holding tank: MDC � (Q01/ �rA60 f OCatch basin/Dry well - Aka On-site system URDURS i 4. Outdoor Surface drains:YES NO JOWN ON6 f AYI(L O Holdint tank. MDC Q o . O Catch basin/Dry wall A 'r .�_ P_y,. C� JV vP AND �Pac!� 0 On-site system WITP A ct-6CONI) L�Y_�OF 5&10-Dg S. Waste Transporter , /►1�Anf�3 .t` Licensed m��llauhe „jlectinatinn !f(�}1(As 'e Prod ict erJ YES_ N0 /'�! VA(cam 1 -x w-- 1xi / NA • L-n- U 2J 81 erson s Interviewed Inspector /Date I , -v 'tr p. t tr',_:`Jts7 Y1 11+ r:1i- BtB#d 4.a1�VlR..,t VHW-001 REV.9/86 •r.' t� ,r j,ftf-:,2aN t•l:a_, t �T:t•r.t t State of New Jersey °. :r •!:,,, .�FA"c�en I- "A •`' Department of Environmental Protection r i",i-. *ro'Tt, Division of Hazardous Waste Management Manifest Section r r CN 028,Trenton,NJ 08625 ` Please type or print In block letters.(Form designed for use on elite(12-pitch)typewriter.) Form Approved. OMB No.2050-0039. Expires 9-30-9I UNIFORM HAZARDOUS 1. Generator's US.EPA ID No:,„t'f-t 4—1 Manifest 2.Page 1 • Information in the shaded areas r v, + Doc ment 0: of is not required by Federal WASTE MANIFEST S T -F', 1 4 r; j 3. Generator's Name and Mailing Address (t'j!j fy, jtjj t t tr, rsrr ,G rr t AA yrr rs e.+ fA State Manifest Document Number ~. r a t N J A I077, i +i 3"�.i v l�c ;r`. r.�'r� :� •�' r _ p, r h,Fr, ?i ;rltt+ h.t 11t1 r¢, n ts. +. jBk"Slate Generator's .1 ,' ."7 t 4 ' .Generator's Phone( zC•t(. )''°7�3- ; 6 a e 5 a Transporterl Company Name L�t ;�{tlGt4trt# �ry US EPA ID Number Si rDAY A ri?.,lt Pv'.u'K4nry h.. VS54, > rry .1 r; I fj Al is i} r �' ^� ;C:�$tate 7,,„Transporter 2 Company,Name.,. ,141.E„ {;}!,,,; 8. lotcsata;er US EPA ID Number!..,,-top i t'D "Transporters.Phone.(�'' ' �w. `. i ,f; a},¢e xi.}t•u, tr!#._p•f'!"±'¢.,5, r• , t r t:�n i-! .:r^ e E.tState Trans ID ;,1, e 9.4' Designated Facility Name and Site Address i 10.•eb1c,-,>3rrti US EPA ID Number '(a01:°porat1.on r'i xn0;;n�,t¢�Fe,r..R:ne� r,;',i :,s + wt` F Transporter'sPhone,(` x ) ? � �* %T At,4'f2,Vre11A6,hUY66a- A'V& „r,h:- Gy State'Facilit ID " tvc Jsn^friv,...r, •1 _ YS h$Yc-tks a Fyy3e,; K k�<j.t 1`)'i 1 J V4 04161 tA id k H.#FBCilityVPhone(#:.;it d 11.;US DOT Description(Including Proper Shipping Name,Hazard Class,and IDNumberJ 12.Containers Total , Unit111, HM No. " Type Quantity Wt/vol Waste No s , 0. E •5'f -a k. _ ,, ' tt:•F! F r;gtl }rog+tr $. �i i :f'et;ra vsrts. .. . e 0to }��.l X4.6.;�. �Ag • R b. , 00411.?%Cb,IE 118`.irvp 1+!f tih t r Y .. pa Z •t _ " s 3'. 'f a t a 4V, N� A , ff!< a i 1SBt ;7 i rf r,r.,!r t ;r e i + , =+ r :qb tL70- i 0 r s� T 'f y.. �iN f1, it„�. +rd, ' z sao33F 31:na,aSrrle: n lurithis .,k,:i +rai;:' , t yd O -t tr f, a AM R C. 't'.i:. N - . .rt F , ice`• t!'F "'nr'S f:- T fi !. ♦ ¢' 4 '. O <tf :i• , ,•,.:,-,.r i t ai t t-#i:.7*...'�t1Y il'�t7fi 7c. ss.zt°_. •. 'ii'f't'<. f'#W�t �t t`k #"#�"�: $ d. ,: a,3 r e , ...� , � t! r t,.., fidr+1 sOrynec4i ei° , va }s. ,"Al, � - .i,t i } h'•'.,+ , ,� ¢ •r i+s^ rr?. '�'t inn ti,adsylr rH i.,ua!!,r iv t- ;ir ��,' ..s t ..< n a�`s�a•*� - .. C J t dditi .nal Descript ons fo Matgjlais Listed Above ' +`` ..r ' �'w t>= K-Handling.Codes for Wastes.Listed Above t f y"'qJ �i Atllf , -" .�.• •& `:"}'*` ax" +. '';, `,. ,#�a,3'�'fi r 1 � -.* ....fib t<at -4� ,.rrt•., # :t<� l /S''* _ Fps' �'.� ,.,.•�"�+`' .�a:,�r a, •:, a- y,"k�,N .' �r� �„ �� _ r., c� A*f��� �f0� L, �.tf�� sti�`' �i- � : � '�� �ma's i.��'.. � 4.. ° • f�� �a � � , 1i e ay�iWj7 � x ��;" " '¢1 " R ,C �a.¢+c:/ # 7st, rs3e,^l :ktgraPd ,. 'et rtSf' tq � m ; �+ ~ ''t•4kFf ? ;4°--� :rtr�fri�x .' -'*b Yi. r a, �i'. xa�,+ 'm r.r # n i e a },rt �. >`J o k, •r��' 3§" i A+ >a >mk*� _� � <° r ? :+t u_g;tr ; 3ardd * 'S ",'a d N".• b "t3 r . f ," a. # gr • d t 15..Special Handling Instructions and Additional Information • 6..< .+ f8 r'R rs:,:iigu i)i *1:.!1t .:a Ad r. #i#-,r:r g;4[*+,. ,- ,., t- , , ; I ..• F.E3� 3 r t.t '"Fe'itll .'. 't!d.1 t.,i n. .tar., ,t sttli„3ti;lra^�}#l�,p,•sr�iJ i'!.d h:f,tr i n e,p:,tt'dr, .x a t;i i :i •..: •. =1i f° 4�Tt.'YP'¢'.rr •^i t'r<!..,r'r sr , .A{ A rrii;nt 16. GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway $ according to applicable International and national government regulations.,,t,••+, ; ,••,@' . , E •If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economically practicable and that I have selected the practicable method of treatment,storage,ordisposa currently available to me which minimizes the present and future threat to human health and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select a the best waste management method that is available to me and that I can afford. Printed/TypedName ,•4 '+' v�•t Signature Month Day Yearr '... . . s" n� r• -.N' }. E t T 17. Transporter 1 Acknowledgement of Receipt of Materials t t rt •, ' m R A rinte(d./Typed Name d Signature t< • Month De Year C $ 5 +��• 4lde"P'`� i F�'/Y� r ; }� .,�.. r •�� -n' y 't. r`' O 18. Transporter 2 Acknowledgement of Receipt of Materials R q . T �f r¢Printed/Typed Name It 1 r rr -�!r. S :Ct+' Signature i ,+t,r `, Clio Month Day Year rr E r i •tr r. ,t i R " 19 Discrepancy Indication Space : »r F ...�.Y..y 41.`•-.. y,.y#r-a t._t :t t. ^s:^ �r..,ii - _, h.r A .s.if,yr a6, r i a r! t h, t C r,IF"34!,St t- o•" T 20. Facility Owner or Operator:Certification of receipt of hazardous materials covered by.this_manifest except as noted in Item 19. r Printedfryped Name,.- c ,; Signature Month Day Year ii-A. EPA Form 8700-22(Rev.9/88)Previous editions are obsolete. "'""`' SIGNATURE AND INFORMATION MU LEGIBLE ON ALL COPIES" - 8—GENERATOR COPY - TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM � -, f / Mail To: NAME OF BUSINESS: G- Board of Health MAILING ADDRESS: Town of Barnstable TELEPHONE NUMBER: 77 5 /9'6 r. P.O. Box 534 CONTACT PERSON: Wt e 6?e 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: 3 41po /< f frie 2 � 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 ra�50-galns-Frgid vawm—,Z � 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, vmdre trans 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) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy- Health Department/ Canary Copy-Business TOWN OF BARNSTABLE c MPzrANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH . 3.Auto Body Shops _ 0 unsatisfactory- 4.Manufacturers COMPANY (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS Clagg: 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: tj waste motor oil(C) new motor oil(C) VIM transmission/hydraulic '. Synthetic Organics: degreasers Miscellaneous: DISPOSAL/RECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply O Town Sewer OPublic `On-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 NO O S: 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. - 14 oii s)lifierviewed ns ector Date