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+ Date:
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: 61f � ��1 (-ee"
BUSINESS LOCATION: A sc�ek, s t- 4cea 11n S l 62601 INVENTORY
MAILING ADDRESS: TOTAL AMOUNT:
TELEPHONE NUMBER: - +461
CONTACT PERSON: Imcch'tilt �h
EMERGENCY CONTACT TELEPHONE NUMBER: 11 MSDS ON SITE?
TYPE OF BUSINESS: sPA-
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: 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
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
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants hjpA & id h
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal 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
(�05 odS� Paints, varnishes, stains, dyes _ _ Other_chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
O` ❑ 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 r may be toxic or hazardous (please list):
Metal polishes 1 ye �►�Iz� PHIS ()u fb MQ rV*
Laundry soil &stain removers _
(including bleach) C k Dint&,
Spot removers &cleaning fluids ``^, 1
(dry cleaners) ( �U��IJ , I � U (1z jS
Other cleaning solvents
Bug and tar removers j�(�l ufiver..
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials