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HomeMy WebLinkAbout0125 WEST MAIN STREET - HAZMAT I)5 we5� Min �q o . ko oF1HE roy Town of Barnstable C/o Office:508-862-4644 Public Health Division Fax:508-790-6304 7 BARMARSBLE.g` 200 Main Street• Hyannis, MA 02601 %639.'M `00 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT RFD MA'S Business Name: Date: y Location/Mailing Address: a Contact Name/Phone: Inventory Total Amount: _ MSDS: License#: Tier II : n Labeling: Spill Plan: Oil/WaterSeparator: A Floor Drains: T1® Emerciency Numbers: Storage Areas/Tanks: C Emergency/Containment Equipment: abso Waste Generator ID: Waste Product: fS r� Date&Amount of Last Shipment/Frequency: S �V Licensed Waste Hauler&Destination: 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 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 soline,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 RECO M ATIONS: 14n, An 10/1S d � Inspector: Facility Representative: WHITE COPY- HEALTH DEPARTMENT/CANARY COPY-BUSINESS F �I Number Fee 1347 THE COMMONWEALTH OF MASSACHUSETTS $15o.00 Town of Barnstable Board of Health This is to Certify that The Stop & Shop Supermarket Co. -Stop & Shop Fuel Facility ..------------------------------------------------------------------------------------------------------------------------------- 125 West Main Street, 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 I { Town of Barnstable Inspectional Services BARNSTABLE fMiSiaiS�NF'- 05WLR -z 1T�Si&.RNh5TIS Public Health Division 6 2014 RAMMB.E. s Thomas McKean, DirectorNAM 1659. 200 Main Street, Hyannis,MA 02601 r Office: 508-862-4644 Fax: 508-790-630i�' 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 VV1,�p�C;�1 *A late charge of$10.00 will be assessed if payment is not received by July 1st. C� 1 ci 1. ASSESSOR'S MAP AND PARCEL NO.. 2. IS THIS A PERMIT RENEWAL? AES_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:. Sao Y- SOt'- mo kek Co. I--t—C- 5. NAME OF ESTABLISHMENT: °F 'S k P'DP1166 6. ADDRESS OF ESTABLISHMENT: � �� CP. A- 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: 10. SOLEOWNER:_G YES_NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: 1 CORPORATION NAME U4 PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT O DATE r d� Q\Application Forms\Haz Mat Appli Draft Jan2019.docx Number Fee 1347 THE COMMONWEALTH OF MASSACHUSETTS $150.00 Town of Barnstable Board of Health This is to Certify that The Stop & Shop Supermarket Co. -Stop & Shop Fuel Facility 125 West Main Street, 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 m Town of Barnstable Inspectional Services BARNSTABLE f • �.�F{ET enn.•r.e:��o��:uirOe ii eC;v"i.�it, t..., Public Health Division • BAMSTABLE. Thomas McKean Director ram: eo a 200 Main Street, Hyannis,MA 02601 t,l^+ R Office: 508-862-4644 Fax: 508-790-6304 t---. APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE4f 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 ❑ CATEGORY 3 PERMIT 500 or more Gallons: $150.00 R P�G�1 *A late charge of$10.00 will be assessed if payment is not received by July Ist. 1. ASSESSOR'S MAP AND PARCEL NO. 990" i ai`00-3 2. IS THIS A PERMIT RENEWAL? YES XNO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONINGBUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES(25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT:—4e yt0 1- 3Ao ,cM 'e_� e D• 5. NAME OF ESTABLISHMENT: hop UO VCt % I 1 6. ADDRESS OF ESTABLISHMENT: ') �L)4'Y'e-e 7. MAILING ADDRESS. IF DIFFERENT FROM ABOVE: The Stop Shop Supermarket Company LLC - Attn: Susan Fox-License Coordinator 1385 Hancock Street 8. TELEPHONE NUMBER OF ESTABLISHMENT: Quincy,MA 02169 Phone: 617-770-6010 m.ce Email: Susan.fox@retailbusinessservices.com EMAIL ADDRESS: _ _. 10. SOLEOWNER: YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TE EPHONE OF: r CORPORATION NAME PRESIDENT TREASURER CLERK 12._IF.PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: • SIGNATURE OF APPLICANT � DATE 1 Q\Application Fonns\Haz Mat App Revised 09-10-18.docx r 1, The Commonwealth of Massachusetts . Department of Industrial Accidents a I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED)KITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly BusinesslOrgaifization NarnejI Address: 1385 Hancock Street City/State/Zip:Quincy MA 02189 Phone#:800-288-8415 Are you an employer?Check the appropriate box: Business Type(required): 1.Q I am a employer with employees(full and/ 5. [D Retail or part-time).* 6. Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. 7. Fj Office and/or Sales(incl.real estate,auto,etc.) [No workers'comp. insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ®Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers' comp.insurance required]* 4.0 We are a non-profit organization,staffed by volunteers, 11.❑Health Care with no employees.[No workers'comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. • lain an employer that is providing workers'compensation insurance for my employees. Below is the policy information. insurance Company Name:AHOLD DELHAIZE AMERICA HOLDINGS, INC.AND SUBSIDIARIES Insurer's Address:1385 Hancock Sreet City;'State/Zip: Quincy MA 02169 Policy#or Self-ins.Lic.#576 - Expiration Date:August 01,2019 Attach a copy of the workers compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, n he pains td penalties of perjury that the information provided above is true and correct Signature: Date: fl jd Phone#:617.6 .4921 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov!dia I -The Stop & Shop Supermarket Company LLC fficers and Managers Title Name President Mark J. McGowan Treasurer Derk-Jan Terhorst Secretary ------_ _- _ -Mark_M.essier--_ Assistant Secretary Maria Silvestri Managers: Mark J. McGowan ven Kienzle rk-Jan Terhorst Stacy Wiggins Robert Yager All Officers & Managers of The Stop & Shop Supermarket Company LLC have the following business address: Stop & Shop Supermarket Company 1385 Hancock Street Quincy, MA 02169 617-770-8708 Retail Business Services Retail Business P.O. BOX 7200 CM services Carlisle, PA 17013 July 23, 2019 CHECK DATE: 07-23-19 TOWN OF BARNSTABLE CHECK NUMBER: 008122089 PUBLIC HEALTH DIVISION CHECK AMOUNT: $150.00 200 MAIN ST HYANNIS, MA 02601 COMPANY: Ahold Delhaize USA SUPPLIER: 107808 --- ---------Dept.-------------------- ---------------------------------------------- ------------------- Invoice Loc. Invoice Number/ Purchase Order Gross Discount Net Date Code No. Reference Number Number Amount Amount Amount 07-19-19 EOTH HAZARD406GAS $150.00 $150.00 TOTAL $150.00 $0.00 $150.00 THE ATTACHED CHECK IS TENDERED IN PAYMENT OF INVOICES SHOWN.IN CASE OF DISCREPANCY PLEASE RETURN WITH FULL PARTICULARS TO THE ABOVE ADDRESS. PLEASE CONTACT THE AFS CUSTOMER SOLUTION CENTER AT 717-960-1700 IF YOU HAVE ADDITIONAL QUESTIONS. - P. I,!Iil� Ad­1�1. ,,.l_1ip- �,T, 7 . .1. ter'fv -,�`�-1. I I 1. I -4ok,i .:: - �V i ,- .1. lAl-. I I Til i, -T, f A ,. 1".. , .. -- — _,, - _Yl -lo, -"'..."I,. dFlloi" 'll g �11`11 1`4 III"I � o. ,I, -�:� I - - .. , , , �iF F I:r- - ` - = - , -i[ 1. � - I—, ., - - - - , I � I ,, ,k.t ..:IjI 'do� kill , 1 I. �Io,l do -. '14- . _ . Ip 4 .� - - I -.1i m I %: - - - Al "11V - .1 I.. h I IN ,.:cl� .:�IF ,IF � 4]u , .I.. �.. ..- � ,I , � 1 Ii.1.I 11 Ili*11 11, ,7.,,�, .It!�..� I - � .11. 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L I . � I j I. � -4AE - --.-- - - -­_­ �------------------� —------------ ----------- � - � _ __ - ­ ­_..--- . ------------------� �------------------------------------ THE 1ph,4 Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 BARMASS. 200 Main Street• Hyannis, MA 02601 �A f6M MPS p�0 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT lED Business Name: S Date: Location/Mailing Address: Ab,;1 Contact Name/Phone: CoSo l ° ,ad-C_, ND V10 57(6 Inventory Total Amount: <500 SDS: $es License#: Tier II : W0 Labeling: - Spill Plan: Oil/WaterSeparator: NO Floor Drains: A (;) Emergency Numbers: Storage Areas/Tanks: 00 G of 2 . Z Emergency/Containment Equipment: f Waste Generator ID: Waste Product: wgl S+-e- %) Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: j rock ,S4mf1)f,(' 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 a/r)d disposal of 111 gallons or more requires a license from the Public Health Division. y Antifreeze Dry cleaning fluids Eutomatic transmission fluid Other cleaning solvents&spot removers ngine and radiator flushes Bug and tar removers —:::::;�klydraulic fluid (including brake fluid) Windshield wash Motor oils 20 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 f. 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: havla- INFORMATION/ `h az w V Inspector: Facility Representative: �/t✓` WHITE COPY- HEALTH DEPARTMENT/CANARY COPY-BUSINESS `�t,�► ti Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 B""M MB ' 200 Main Street• Hyannis, MA 02601 059. .e� TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT rE0 MPS a Business Name: ° o &a s 4 'o D Date: / Location/Mailing Addre s: 12e Oe-s4 Mcjyt, �4- . a-viy'7 6 Contact Name/Phone:S aro 1 �yac'�e. �JrdB- 79b- S71 Inventory Total Amount: 3 b 44-1 f P-Dgb MSDS: opt.11 v-c_ License Tier II : o I I Labeling: re-+an1 Spill Plan: Oil/WaterSeparator: tJIA Floor Drains: h3D Emergency Numbers: y�S Storage Areas/Tanks: '�-` S -10 C ,v,M Emergency/Containment Equipment: ,1 kc l UO c� 5 ,A.e- Waste Generator ID: Waste roduct: aBl���, 9Qs Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: 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 Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) -X Windshield wash I Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: vo o� 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: n ilk 5 VVUR W.�f OA--5 1+e— 1 , [�.� .Y D V 1n ovr S O at, h c l �C ZV e Aid,7� K6A 511\1 �e1" 1 vlN2�J Wl oyl.�lrl(y/ 7- A ns ctor:4,11 �cGor�25 aceDiti S�fi2-S � LU2� �:eX OJS ��GZKVFacilityRepresentative: J- 6$ V�!t e. C o ,vt o Stg<e , 4►2 WHITE CO -HEALTH DEPARTMENT/CANARY COPY-BPSINESS (� K5+I\1I& a-kbI�- 60lvti- 7$1,Wk em-O,, I' o rJve0 14ev7 cony oP i IKE royti Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 BARMS�BLE.g• 200 Main Street• Hyannis, MA 02601 �'0'EDMP+a`0 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: 6to S Vp 6-4 *O O Date: 1 27 !b Location/Mailing Address: o Z 5- e 6f, -fwrt t 5 Contact Name/Phone: h Q ask e— SO 74 0 L 7 I(v Inventory Total Amount: _2�a 1 MSDS: 6 License#: N Tier II : Labeling: CAA-A-, Spill Plan: Yes Oil/WaterSeparator: Floor Drains: Emergency Numbers: ,/e Storage AreaslTanks: — s o Emergency/Containment Equipment: 5 ' j 1e,k m 0yK5 Waste Generator ID: M-J<S �73 S17•1'-F Waste Product: o + X ,14,ec5 Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destinatio Other Waste Disposal Methods: \Z-e-Dllr A k &Jr 13 5 ode 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 Automatic transmission fluid Other cleaning P 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: 0 ow 3 WT 41,I Inspector: + kVew��` Facility Representative: `g1n,�-v�� kesk+ w C�svt`r WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS TOWN OF BARNSTABLE Date: 3 / It TOXIC AND HAZARDOUS MATERIALS FORM NAME OF BUSINESS: 5�ep v p Gat, ogo(o BUSINESS LOCATION: (9,� W. 1NIa,� I�y�,�,n� s INVENTORY MAILING ADDRESS: TOTAL AMOUNT- TELEPHONE NUMBER: moo -Iga S-Itt, < lII CONTACT PERSON: bob \06A\N EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: k TN00_ JA.,J o - MR.� 6,0r"e— INFORMATION / RECOMMENDATIONS: '��Jv O.ear�.k rc�,�� z� C��� ava►I ��,regueS�' 1 Fi�r1e District: C oy.. avl 10�� sv i.tic wa e< <c v��.e s 3 o4,st— r/ 4r�h i4A-a it&cc 00 S A Cori 4� T U) S��I) ►Ci�'S t'iQ��� D�4r. out S��'� Waste T �� of J�1ySyo��D i1oJ Last shipment of hazardous waste: 3 Isola Name of Hauler: `1�iM C hy,ro� ,fA.l Destination: Al 4141--X 6ny1ror VW-1-d,1-j \4 Waste Product: wA, a j5dds 4- s+ s License No lglI >Oy000ggZt— �y 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. Obs rued / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants 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 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 Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's Signature Staff's Initials MASSACHUSETTS FIRE INCIDENT REPORT `• DEPARTMENT Revised 010 1.,9,2,2.......... Hyannis Fire Department Report Form F `* 3:::......:>:» If Ex Date Alarm Arrival In Service # 000652 Fire 007/ 14/97 Day IMonday09.56 110: 19 10.42 `h>SIC TU 0 FOUND ACTION TAKEN ;;: MUTUAL•AID , eak w/ No Ign ;4 1 Remove Hazard XED PROPERTY USE (OCCUPANCY) :: IGNITION FACTOR Paved Public Street ;.<.>9 6 2 NOFIRE «s`0 0 OCORRECT ADDRESS ZIP CODE CENSUS TRACT D 165 YARMOUTH ROAD 0 2 6 0 1 40 O 11 OCCUPANT NAME (LAST, FIRST, MI) TELEPHONE ROOM or APT. N/A OWNER NAME (LAST, FIRST, MI) ADDRESS TELEPHONE F 12 N/A 613 METHOD OF ALARM CO. DIST. rRESP. SONNEL ENG RESP. ........... AERIALS RESP. .'.„;1 a O ' SHIFT HAZ MAT PRESENT? TANK. RESP. JOTHER RESP. RESCUE 828 NO. ALAEMS SUBSTANCE 0 0 1 ' SPEC. EQUIP. USED? O 20 FIRE T SERVICE 0 .. 0<`> : OTHER O MOBILE PROPERTY TYPE VEHICLE STOLEN? ESTIMATED TOTAL INSURANCE CO. DOLLAR LOSS TOTAL INS. CLAIM PD • 0 >> 0 0 30 YEAR MAKE MODEL COLOR LICENSE NO. VIN# 40 IF EQUIP INVOL. YEAR MAKE MODEL SERIAL NO. IN IGNITION OCOMPLEX JAREA OF EQUIP INVOLVED IN IGN. K ORIGIN FORM OF HEAT IGNITION j""'%'----'':;::::::'::: MATERIAL FORM -- TYPE © IGNITED ............ . ........... OMETHOD OF LEVEL OF ORIGIN Number of Stories CONSTRUCTION TYPE EXTINGUISHMENT Lj Q EXTENT OF DAMAGE Flame .. Smoke DETECTOR PERFORMANCE SPRINKLER PERFORMANCE LL�A Ll 0 Material generating FORM TYPE no Material smoke AVENUE OF SMOKE TRAVEL R WEATHER CONDITIONS Officer in Charge: Date ERIC FARRENKOPF CAPTAIN 7/ 1 4/9 7 Comments for this incident have been printed on an additional comments page. r Comments for Incident: 97 000652 Exposure: 00 Date: 7/14/97 vCEIVED A CALL FROM RESCUE 828(CAPT.J.CABRAL)ON LOCATION OF AN MVA AT YARMOUTH ROAD IN FRONT OF CAR WILLIES(R-971732) FOR ENGINE 826 TO RESPOND FOR TRANSMISSION FLUID IN THE ROAD. RESPONSE:ENGINE 826 CAPT E. FARRENKOPF,F/Fs SZURLEY,HOLIGAN. UPON ARRIVAL HAD AN APPRCX 2 OT.SPILL OF TRANSMISSION FLUID IN THE ROADWAY. COVERED THE SPILL WITH SPEEDI DRI,SWEEPT UP THE SOAKED SPEEDI DRI AND RECOVERED THE SPILL AREA.VEHICLES REMOVED BY DAVIS TOWING. ENGINE 826 TO OTS 1042 ERIC FARRENKOPF CAPTAIN 07/14/97 • TOWN OF BARNSTABLE - -UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION MAP NO. = PARCEL NO. ADDRESS OF TANK: I J� !- Plrlmi VILLAGE: Yt/!/{ALAIl.S `�J '� ,� MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) : f117 �11�� �'1/# Xr't ' rUJr?/j1 Irlf.'1. t'��/JY 7 f x r OWNER NAME: 4 k6r D \ • "�o" t lvk, PHONE: sy ' l#'/-17V INSTALLATION DATE: \:lWe.. !`370 BY: I(WA?&') t Cf',l<Le.. i-bi lom J Y Y INSTALLER ADDRESS: CERT.NO. *TANK LOCATION: t ((`A1 f``{ b11!Ul4--r! / i'111k 71)d DtYCR I ft, TANK I:.00AT IJtON WITH MKORKCT TO HU I l_D I Nm.) , CAPACITY ffit)tT /XJTYPE OF TANK l �. AGE 0 YRS. FUEL/CHEMICAL 64�5011�1 TESTING CERTIFICATION C V] PASS [ ] FAIL DATE l '1t ,. LEAK DETECTION [ ] CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION [i ] YES [ ] NO DATE TO BE REMOVED FIRE DEPT, PERMIT ISSUED [ 7 YES [ ] NO DATE CONSERVATION [ ] CHECK IF N/A DATE * BOARD OF HEALTH TAG NO. [ f'�7 ] DATE '" f! 7 r f PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD TOWN OF BARNSTABLE - UND FUEL AND CHEMICAL STORAGE REGISTRATION ` / MAP NO. Ire PARCEL NO. [i/- r'l t�11U i VILLAGE: 11t AIAJ a ADDRESS OF TANK: p Num bar l MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) : OWNER NAME: �1�'s 'i)� C�t PHONE: , INSTALLATION DATE: J A)e 1n-1q By: �fliA) + r TNSTALLER ADDRESS: CERT.NO. *TANK LOCATION: r� )� "� (Diwo#R-x n r k"LOC mmapECT T O CHU I"0 I NO) f CAPACITY /0MV 4TYPE OF TANK f= iXrtP� AGEi WRS. FUEL/CHEMIAL TESTING CERTIFICATION C✓]PASS C J FAIL DATEU' tI�i j ' f / Q LEAK DETECTION [ ] CHECK IF N/A TYPE/BRAND t�J�` r`��'d ZONE OF CONTRIBUTION C J YES Ckf NO DATE TO BE REMOVED ' FIRE DEPT. PERMIT ISSUED C J YES [ J NO DATE CONSERVATION C J CHECK IF N/A DATE BOARD OF HEALTH TAG NO. [ / ] DATE 14 ,J PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION O MAP NO. PARCEL NO. ADDRESS OF TANK: / L-t/• 111,11AJ VILLAGE: Alt I A)V I.S Number v a*-- f /' / /. MAILING ADDRESS ( I F D I FFERENT FROM ABOVE) : �� IQV51i4e1 4'4 /bl oA.Jhgk) �1' �. oI gI Cj4 OWNER NAME: �J �`' 1 &WISA, PHONE: 3 /&e- INSTALLATION DATE`: Jt1tj BY: P kWh°I1 I^!STALLER ADDRESS ! f '� ' �,r"�. "7'. / CERT.NO. *TANK LOCATION: ���� /�7 Uil�filslJt'1 � ill! aLF{ (OKSC.R f ii TANK LOCATION tl i TM 1'1ifi�iCT TO mu I'LD I Nm) ,�Ov,b1, CAI{f .,,•,r _�t :Ya..,t., ` � CAPACITY .660 TYPE OF TANK A.f jy-fprCfA AGE O YRS. FUEL/CHEM I CAL 615 /it,/e ' � ��txr�la5s• i� TESTING CERT I F I CATRI ON [VT PASS [ ] FAIL DATE juAJe- Irmo -r LEAK DETECTION [ ] CHECK ,'!F �N/A;, TYPE/BRAND / �S ISO ZONE` OF CONTRIBUTION [ ] YES [ ] N0 4, DATE, TO,;�`E,, REMOVED ? FIRE DEPT. PERMIT ISSUED [ 7 YES [ ] NO DATE CONSERVATION [ ] CHECK IF N/A '" DATE- ! BOARD OF HEALTH TAG NO. [ ,/r ." ,;� 7 DATE 'S°"' '"' 4)y. PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD .. _. .. .. .. a %.. .. ... _ ... .. _ l { S�,C,cV— A A J r TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF FIRM: J.R. Sousa & Sons , Inc. MAILING ADDRESS: 29 Andover Street, Danvers , MA 01923 TELEPHONE NUMBER: 617-777-1500 CONTACT PERSON: Win Milstrey, Operations Manager Does your firm store any of -the-toxi-c -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 X 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: 125 West Main Street, Hyannis , MA 02601 TELEPHONE: 617-7 71-1511 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: j X Antifreeze (for gasline or coolant systems) Refrigerants Automatic transmission fluid Pesticides (insecticides, Engine and Radiator flushes herbicides,rodenticides) ;I Hydraulic fluid (including brake fluid) Photochemicals —� Motor oils/waste oils Printing Ink X Gasoline, Jet fuel Wood preservatives X Diesel fuel, Kerosene, #2 heating oil (creosote) A Other petroleum products: grease, Swimming Pool chlorine lubricants. Lye or caustic soda Degreasers for engines and metal Jewelry cleaners Degreasers for driveways & garages Leather dyes Battery acid (electrolyte) Fertilizers (if stored Rustproofers outdoors) Car wash detergents PCB' s Car waxes and polishes Other chlorinated hydro- Asphalt & roofing tar carbons, (inc.carbon Paints, varnishes, stains, dyes tetrachloride) Paint and lacquer thinners Any other products with Paint & Varnish removers, deglossers "Poison" labels (including Paint brush cleaners chloroform, formaldehyde, Floor & Furniture strippers hydrochloric acid, other Metal polishes acids) Laundry soil & stain removers Other products not listed (including bleach) which you feel may be Spot removers & cleaning fluids toxic or hazardous (please (dry cleaners) RECEIVED Other cleaning solvents HEALTH DEPT, list.: . Bug and tar removers TOWN OF BARNSTABLE Household cleansers, oven cleaners Drain cleaners Toilet cleaners Cesspool cleaners MAY 8. 1g81 Disinfectants Road Salt (Halite) l _ TOWN. O F B R N STA B L E COMPLIANCE: CLASS: 1. Marine,Gas Stations,Repai.r satisfactory, 2. Printers BOARD OF; EALT'H 3.' 'Auto Pody Shops .unsatisfactory- . 4. Manufacturers COMPANY . ;A' , 4 ; J ''lt (see"Orders") S. Retail Stores 6. Fuel Suppliers ADDRESS ., 7�a- Class: 7. Miscellaneous QUANTITIES AND STORAGE (IN=indoors; OUT=outdoors)' MAJOR MATERIALS Case lots Drums AboveTanks Undetground Tanks IN OUT IIN IOUT ( IN IOUT Lyellonse rest? Fuels: Gasoline, Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste -motor oil (C) new motor oil (C) . transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: DISPOSAL RECLAMATION REMARKS: 1. Sanitary Sewage 2, Water Supply OTown Sewer O Pub t i c ._ OOn-site Q Private 3. Indoor Floor Drains: YES NO O Holding tank: MDC 0 Catch basin/Dry well 0 On-site system +� 4. Outdoor Surface drains:YES NO O Holding; tank: MDC ° O Catch basin/Dry well 0 On-site system S. Waste Transporter Licensed? Name of Hauler- DestinatiRn WastC Product 2. 12 23 81 Person(s) Inp rvie d —,01—Inspector D e