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Home My WebLink About0725 WEST MAIN STREET - HAZMAT vi Mal 7 \ TOXIC AND HAZARDOUS MA RIALS REGISTRATION FORM �" � Mail To: NAME OF BUSINESS: 4 Board of Health MAfLING ADDRESS: 79-5- Town of Barnstable TELEPHONE NUMBER: 7Ze- p 5"® P.O. Box 534 CONTACT PERSON: 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 totalli at anytime, 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 i Please put a check beside each product that you store: Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business J`r Ifs TOWN OF BARNSTABLE OMPIdANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops O unsatisfactory- 4.Manufacturers COMPANY (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS Class: -7 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 ls: GaLNige,Jet Fuel(A)' Dies , erosen� , #22,(B) �e iY S:C:�s'yL��►t,c,� w tomvWr7vft(C) ew motor oil (C) tran missioydraulic Synthet Organics: degr aser scellaneous: DISPOSALIRECLAMATION REMARKS: 11/'1.�Sanniitary Sewage `�2.Water Supply C�'Town Sewer O°Public O On-site OPrivate 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: A/ O Holding tank:MDC Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product .51YES NO h �2. ls' , Person (s) In rviewed Inspe/�"` Date TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM Mail To: NAME QF BUSINESS: �, � '� °� Board of Health MAILING ADDRESS: 7^- AIV A& Town of Barnstable TELEPHONE NUMBER: P.O. Box 534 Hyannis, MA 02601 CONTACT PERSON: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totallin , 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.' Please put a check beside each product that you store: Antifreeze (for gasoline or coolant systems) Drain cleaners ,bl�: Automatic itransmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with"Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please)i/st): (dry cleaners) Other cleaning solvents Bug and tar removers YV�} Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business �� r"'� �,.r y,r-•..-.,.,,+.....n«n..�...,,;v..y�yr».....-.r.v-...•..ss--aF- ��r�r:4.T _.s.*uu.-^.:y.,�..�......f *-t...s�^�1"","�,+....y. ..,..r ....•.. ..., r. _ Y � .., t.; _.� � _ 6 y .-TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM Mail To: NAME OaF BUSINESS: Board of`Health ,Al ` / MIL'ING ADDRESS: '7 - Town of Barnstable�`�. y r TELEPHONE NUMBER: 0 P.O. Box 534 CONTACT PERSON: Hyannis, MA 02601 i Does your firm store any of the toxic or hazardous materials listed below, either for sale or for our own use, in quantities totalling,,, at an time, more than 50 gallons liquid volume or 25 bounds `' Y Q g•; Y 9 q 2 P dry weight?, ,YES NO M. 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: f ADDRESS: ` TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous F characteristics and must be registered when stored�inquantiti_es�totallingrmore than: a_II nsliquid volurrmesora25t,poundstd.ry weight, Please put,a check beside each product that you store: _ g 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 { I'• . Motor oils/waste.,.: •_ -.�.>. ..:- F �.� _ .a�,�,,� ,::�, _• � oils Roa ad S41t (Halite)` Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, r Other petroleum products: grease, lubricants rodenticides) k' a Degreasers for engines and metal /4"61-lotochemicals (fixers and developers) ty` Degreasers for driveways & garages Printing ink . ` Battery acid (electrolyte) Wood preservatives (creosote) .3. Rustproofers Swimming pool chlorine <` Car wash detergents Lye or caustic soda 't 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, F.aint:br;ush 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 ,r Bug and tar removers Household cleansers, oven cleaners } White Copy-Health Department/ Canary Copy-Business TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair BOARD OF HEALTH O satisfactory 3. i Body Shops O unsatisfactory- 4.Manufacturers COMPANY (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS Class: 7 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALSCase lots Drums Above Tanks Underground Tanks IN OUT IN OUTI IN OUT #&gallons Age Test els: soline,Jet F (A) Kero e, #2 (B) fKa waste ) ew motor oil (C) transmi sio ydraulic Syntheti r anics: degre sers Miscellaneous: DISPOSALlRECI.AMATION REMARKS: V. Sanitary Sewage V2. Water Supply s% �6� ��✓�� O Town Sewer OPublic O On-site OPrivate . Indoor Floor Drains YES NO O Holding tank: MDC _ O Catch basin/Dry well A O On-site system V 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 6 4640fYES NO yt Person (s) Interviewed Inspector Date TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1. Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH O 3.Auto Body Shops ' O unsatisfactory- 4.Manufacturers COMPrA'1VY (see"Orders") 5.Retail Stores 6.Fuel Suppliers .ZE RESS Class: 7 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground IN OUT IN OUT t IN OUT #&gallons Age Test a 'Fuels: Gasoline,Jet Fuel'(A) ` Diesel, Kerosene#2 (B) " Heavy.Oils: waste motor,oiR(C) new motor oil (C) transmission/hydraulic 1� SyntheticyOrganics: degreasers Miscellaneous: DISPOSAURECLAMATION REMARKS: V1. Sanitary Sewage V 2.Water Supply 77/-4 AF1 O Town Sewer OPublic Q On-site- —.� OPrivate 3. Indoor Floor Drams' YES'- .-.NO O Holding tank: MDC O Catch basin/Dry well O On-site system V4. 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 S NO t V2. U W /44y Person (s) Interviewed Inspector Date