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TOXIC_ AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS: Board of Health
MAILING ADDRESS: 4 Town of Barnstable
TELEPHONE NUMBER: .�Y. �` P.O. Box 534
CONTACT PERSON: F' 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 totallin , at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NC
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 store
*::'Please put a check beside each product that you store:
F
�'�✓ 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 iremovers 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) ?' l
Other cleaning solvents -✓�
Bug and tar removers
Household cleansers, oven cleaners
White Copy- Health Department/ Canary Copy-Business
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TOWN OF BARNSTABLE COMPLIANCE: 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 ;' t (;jags: °� 7.Miscellaneous
ANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS Case lots Drums Above Tanks Underground Tanks
IN OUT IN OUT IN OUT #&gallons Age Test
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:
DISPOSALIRECLAMATION REMARKS:
1. Sanitary Sewage 2.Water Supply
O Town Sewer jffublic
n-site O Private
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 f ORDERS:
Q Holding tank: MDC
O Catch basin/Dry well
O On-site system
5.Waste Transporter
Name of Hauler Destination Waste Product
YES NO
1.
2.
Person (s) Intervie d Inspector Date