HomeMy WebLinkAbout0188 WINTER STREET - HAZMAT J 188a-I, �� �z�m�7
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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS: '774DWA44A2 Board of Health
MAILING ADDRESS: >? � `�~Z�`' Town of Barnstable
TELEPHONE NUMBER:- 77/- �"� P.O. Box 534
CONTACT PERSON: <40-!72 „r
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 totallipg, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NO V
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) ,5' ,mod,yy S
Other cleaning solvents
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.Auto Body Shops
/� O unsatisfactory- 4.Manufacturers
V-oAy,,X o,y (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS /�'8 //w��- �S�r Class: 7•Miscellaneous
QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS Case lots Drums Above Tanks Underground Tanks
IN OUT IN OUT IN OUT #&gallons Age Test
'S.
Ga (line,J uel�(A)
Diesel, Kerose e 2 (B)
O ,qav '
J 4 waste 4we"Mikoe)
ew motor oil (C)
tran mission/hy aulic
Synth 'c Or anics:
degreas
71aneous:
DISPOSAL/RECI.AMATION REMARKS:
✓1. S nitary Sewage V2. Water Supply
Town Sewer Public G+
O On-site OPrivate
V3. Indoor Floor Drains YES NO
O Holding tank: MDC
O Catch basin/Dry well j
O On-site system
114. Outdoor Surface drains:YES NO
Q Holding tank:MDC
O Catch basin/Dry well F s�
O On-site system
r5.Waste Transporter
Name of Hauler Destination Waste Product
YES NO
2. ��--
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*Ferscn ) Interviewed Inspector Date