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HomeMy WebLinkAbout1112 MAIN STREET (OST.) - HAZMAT fMzmqT r r� TOXIC kND Y!+ZARDJUS "._TERI ALS I LGISTKATION NAME OF FIRM: �GS�J�I �jf'l���L ��9N�SCh'�c S��l/iG MAILING ADDRESS: / ���N ''i. ©5Tixx /� TELEPHONE NUMBER:yay� 1pr� S`�j 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 totalling, at any time, more than SO gallons liquid volume or 2S pounds dry weight? YES NOK_ 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 i or hazardous characteristics and must be regi-stered when stored in quantities totalling more than SO gallons liquid volume or 2S pounds dry weight. Please put a check beside each product that you store: i Antifreeze (for gasline or coolant systems ) Refrigerants Automatic transmission fluid Pesticides (insecticides, Engine and Radiator flushes herbicides,rodenticides ) Hydraulic fluid (including brake fluid) Photochemicals Motor oils/waste oils Printing Ink Gasoline, Jet fuel _44r- Wood preservatives Diesel fuel , Kerosene, #2 heating oil Other petroleum products: grease, (creosote) f Swimming Pool chlorine lubricants Lye or caustic soda ! Degreasers for engines and metal Jewelry cleaners t Degreasers for driveways & garages Leather dyes 4 ° Battery acid (electrolyte) Fertilizers ( ' Rustproofers ) 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 j (dry cleaners ) list) : i Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners Drain cleaners Toilet cleaners Cesspool cleaners Disinfectants Road Salt (Halite) satisfactory 2. Printers BOARD..- O� HEALTH ?. �, i 3.,,Auto Plody Shops 0unsatisfactory- ! 4. tanu>fact rers � lC � "-,� i see"Orders• S. Reta).1 Stores COMPANY: ( ) • 6. Fuel Suppliers ADDRESS '� 1I I Z volGLtv� Classt 1. Misc lIanevus 1 QUANTITIES AND SYORAGE (.1 Indoors; OUT=outdo MAJOR FfA7ERIALS! Case- loitls V , DruSn9•-•'t'.r., AboveTanks Undetgrouad 'ranks I!J 1 MU otrr _TT I N 6 ce I Ions Aver U Fuels: Gasoline, Jet Fuel (A) t„ Diesel, Kerosene, 12 (B) • 1eaVy Oils: waste motor oil (C) new motor. oil (C). transmission/hydraulic Synthetle :Organics: + degreasers Ice 1 v 1 �� �: '�: fI �•,..a ` ! I:.. � �—`—TTT IF 1liscbfilaneous: r. Ir I l 'tR'I� 1, { ,it Ir.'ll.{ '�'tlfr1i !• -n f � � :i, r�I ISPua'L7 tEG�lA Ut _. fih P 1. SanitarySewage. 1 t>lK�t . It f�l111 �41111 2. Wi kflrfSsoplfly -s I�r I Ii�rl, 11/1.ilrll I .i f r1 U►rl `J , �bwn Sewer Pt�Ibli I ly On-site rtt-' 1 i1',I �10 t. Pzliira�te . ..........._.. , 30 Indoor Floor Drains: YES Np X, Q Holding tstnk:, MUC n� ) � ' ✓� t � -� ; � , , O Catch basin/Dry well Un-site system ---- 4. Outdoor Surface drains.-YES No { IluldinE• tank: MUC O Catch basin/Dry well On-site system S. Waste Transporter Licensed? ..are of Hauler_ •Jle tinatIan _ Waste Prod uc - 2. r fi u �gin! I 1 1 . '—� ' •erson ntery ewe f r .) n�s.perctJt"o.(1."r'.•,:{ . Date i TOhIN OF BARNSTABLE BOARD OF HEALTH TOXIC AND HAZARDOUS MTERIALS REGISTRATION FORTS NAME OF FIRM: CO MAILING ADDRESS: %I/� ef,ti S� �s�e� v I I� �/° TELEPHONE #: 4 CONTACT PERSON: j o ( h �/q r Ago f S Does your firm store any of the toxic. or hazardous materials listed on the follow-: ing page, 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 Vol NO If NO, please ignore the rest of this form and return it to the Board of Health. If YES, please answer. the .following questions and return it to the Board of Health. If materials are stored at a site other than the above address, please state: i ADDRESS; TELEPHONE:- �d - What is the approximate total amount of all your listed materials at any time? 50 gallons - 100 gallons _�ED gallons - S00 gallonsmore than 500j 25 pounds - 50 pounds 0 pounds - 100 pounds gallons or 2S0 pounds Examine the list of toxic and hazardous materials carefully and identify each one your firm stores.: Enter the Storage Code in the blank beside each product to describe your means of storage. STORAGE CODE 1 . Outdoor Storage a) sealed barrels, drums, cans d) glassware (bottles) b) aboveground tanks e) bags or boxes c) underground tanks f) open, loose or uncovered h 2. Indoor Storage j a) sealed barrels, drums, cans d) glassware (bottles) b) aboveground tanks e) bags or boxes c) iinbreakable bottles (plastic) f) open, loose or uncovered Example: lc gasoline 2a paint removers i 2c swimming pool chlorine le fertilizer (only if stored outdoors) NNME OF FJPkl: ADDRESS: TOWN OF BARNSTABLE BOARD OF HEALTH 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 or 25 pounds dry weight. Please enter t1ie Storage Code in the blank to the left of each product you store. �j Antifreeze (for gasline or coolant systems) Pesticides (insecticides, Automatic transmission fluid herbicides, rodenticides) Engine and Radiator flushes Photochemicals c�4 Hydraulic fluid (including brake fluid) Printing ink Motor oils/ Waste oils Wood preservatives (creosote Gasoline, Jet fuel Swimming pool chlorine Diesel fuel, Kerosene, #2 heating oil Lye or caustic soda Other petroleum products: grease, lubricants Jewelry cleaners Degreasers for engines and metal Leather dyes Degreasers for driveways and garages Fertilizers (if stored out- Battery acid (electrolyte) doors) Rustproofers PCB's Car wash detergents Other chlorinated Car waxes and polishes hydrocarbons, (inc. carbon tetrachloride) Asphalt and roofing tar Any other products with 4_ Paints, varnishes, stains, dyes "Poison" labels (including 19 Paint and lacquer thinners chloroform, formaldehyde, hydrochloric acid, other Paint and varnish removers, deglossers acids) Paint brush cleaners - Other products not listed Floor and furniture strippers 1.7hich" you feel may be toxic : Metal polishes or hazardous (please list) :_. Laundry soil and stain removers (including bleach) Spot removers and cleaning fluids (dry cleaners) .Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners Drain cleaners Toilet cleaners Cesspool cleaners Disinfectants Road Salt (Halite) Refrigerants. TOWN OF BARNSTABLE BOARD OF HEALTH Toxic and Hazard-ous Components PRODUCT TOXIC OR HAZARDOUS COMPONENTS Antifreeze (gasline or coolant systems) methanol, ethylene glycol Automatic transmission fluid petroleum distillates, xylene Engine and radzllor flushes petroleum solvents, ketones, glycol ethers, butanol. Hydraulic fluid '(including brake fluid) hydrocarbons ; fluorocarbons Motor oils/ waste oils hydrocarbons Gasoline, Jet fuel hydrocarbons, lead Diesel fuel, kerosene, 42 heating oil hydrocarbons Other petroleum products: grease, lubricants hydrocarbons Degreasers for engines and metal chlorinated hydrocarbons; toluene, phenols, dichloroperchloroethylene Degreasers for driveways and garages petroleum solvents, alcohols, glycol ethers Battery acid (electrolyte) sulfuric acid Rustproofers phenols, heavy metals Car wash detergents alkyl benzene sulfonates Car waxes and polishes petroleum distillates, hydrocarbons Asphalt and roofing tar hydrocarbons Paints, varnishes, stains, dyes heavy metals, toluene:: _ Paint and lacquer thinners acetone, benzene, toluene, butyl acetate, methyl ketones Paint and varnish removers, deglossers methylene chloride, toluene, acetone; xylene, ethanol, benzene, methanol Paint brush cleaners hydrocarbons, toluene, acetone, methyl ethyl ketones, methanol, glycol ethers Floor and furniture strippers" xylene Metal polishes" petroleum distillates, petroleum - naptha, isopropanol Laundry soil and stain removers (including bleach) petroleum distillates, tetrachloroethylene Spot removers and cleaning fluid (dry cleaners) hydrocarbons, benzene, "trichloro- ethylene, 1,121 trichloroe:thane Other cleaning solvents ., pure strength benzene, acetone, trichloroethylene Rock Salt (Halite) sodium chloride concentration Refrigerants 1,1,2 trichloro-1,2,2 trifluoro- ethane t- r ' ` TOWN OF BARNSTABLE BOARD OF HEALTH Toxic and Hazardous Components ; PRODUCT TOXIC OR HAZARDOUS COMPONrS Bug and tar removers petroleum distillates,. xyj.e Householdcl.eansers, oven cleaners petroleum distillates, xyi:ol glycol ethers, isopropano. H ' y Drain cleaners 1,1,.1 trichloroethane ' Toilet cleaners chlorinated phenols, xvle- sulfonates Cesspool cleaners tetrachloroethylene, -methi•ne chloride, dichlorobenzene Disinfectants cresol, xylenols Pesticides (insecticides, herbicides, rodenticides) napthalene, phosphorus, x, ne heavy metals,chloroform, chlorinated h. Photochemicals phenols, sodium sulfite, cni potassium bromide, silver _li Printing ink heavy metals, phenol-form z'i Wood preservatives (creosote.) pentachlorophenols Swimming pool chlorine sodium hypochlorite Lye or caustic soda sodium hydroxide Jewelry cleaners sodium cyanide t Leather dyes formic acid Fertilizers (if stored outdoors) arsenic, nitrates, ammonium, sulfur a heavy metals, formaldehyde, phosphoric ad ' PCB►s chlorinated hydrocarbons carbon tetrachloride chlorinated hydrocarbons ;T' •• — ........�,.- .ter-.- �...... ...}.` ... .. 77 .x $-fie.•. .-r" k—":- .. .. .:..-. :_-::.: _ ._. ., :. Kit - _ •.. _. -.,t•.'` - a.;:»t ^ y TOWN OF BARNSTABLE BOARD OF HEALTH r - Toxic and Hazardous Materials Inventory Form NAME OF FIRM: 7C Z` , �C�iJ �'V C L►I tJ r: ADDRESS: STORAGE LOCATION: < r of Me- ` PERSON RESPONSIBLE FOR INVENTORY: h,c�i/ r dtic is �f PRODUCT TYPE OR USE: . BRAND NAME (if any) : FULL LIST OF COMPONENTS/INGREDIENTS: MONTHLY INVENTORY (denote units: gallons, pounds, etc.) JANUARY FEBRUARY MARCH APRIL MAY JUNE itial Initial Initial Initial Initial Initial stock stock stock Stock stock Stock irchase Purchase Purchase Purchase Purchase Purchase )tal input Total input Total input Total input Total input Total input LT ile Sale Sale Safe Sale Sale ,'rt.'' 3e Use Use Use Use Use k 'isposal/ Disposal/ Disposal/ Disposal./ Disposal/ Disposal/ :- ISte Waste Waste Waste Waste Waste r :)tail outgo Tot:zl outgo Total outgo Total outgo Total outgo - Total outgo tuck at end Stock at end Stock at end Stock at end Stock at end Stock at 'endt,`' �0 (01tional — to be used at the ddscretion of the Board of Health in selected cases) TOWN OF BAf NS1TA LL .oy`shopS _ 2 Printers satisfactory AutBOARD OF PEA— ""%, .3.4. Manufacturers r unsatisfactory- " ,� -(see"Orders") 5.,,Retai.l Stores COMPANY `� "6. Fuel Suppliers ` p 7. Miscellaneous ADDRESS QUANTITIES AND STORAGE (IN=indoors; OUT=outdoor: MAJOR MATERIALS Case lots Drums AboveTanks Underground Tanks IN VUT IN OUT I N & gel-Ionse rest FWasoline, Jet Fuel '(A) Diesel, Kerosene, N2 (B) Heavy Oils: waste motor oil (C) . new motor oil (C) transmis ' .n/hydraul� Synthetic Organics: de reasers f Miscellaneous: DISPOSAL -RECLAMATION REMI.RKS: 1. Sanitary Sewage 2. Wat Supply OTown Sewer - O Public ' 1_ On-si e 0 Prive �e In oor 1 Dr 'ns: YES NO olain ank: MDC Catc asin/Dry well RVERS — 14/1 4 'CJ On- ite system 4.\Outdo r Surface drains-,YES NO- 1 r v v •Holding• tank: MDC _ I t; ,�• - m'., Catch basin/Dry well — OOn-site system 5. Waste Transporter { 1 Licensed? -Jame of Hauler_ j2gctinatinn 1 F u :� ei Person s) Int.erViewed nspector U to TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM Mail To: NAME OF BUSINESS: l Board of Health MAILING ADDRESS: �� "� � Town of Barnstable TELEPHONE NUMBER: 53 P.O. Box 534 CONTACT PERSON: _� 1"t2l �� 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 tot Ilin 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 ' qi 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 �odenticides) 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 hazardo s (please list): (dry cleaners) 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 2.Printers 3.Auto Body Shops O unsatisfactory- 4.Manufacturers COMPANYI</_ (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS 1/1Z 17) ass• 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 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: DISPOSALIRE(;LAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply O Town Sewer Public 4'On-site OPrivate 3. Indoor Floor Drains YES N04 O Holding tank:MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NOjL ORDERS: O Holding tank:MDC O Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product / YES NO 2. 1-557- 'PeN6A s erviewed ` _ Inspector Date