HomeMy WebLinkAbout0021 POND STREET BLDG 1 UNIT 4 - HAZMAT --�C ---I-
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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS: ei; &6 k ' Board of Health
MAILING ADDRESS:
7 � ! 'l/'� �-�e Town of Barnstable
TELEPHONE NUMBER: 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 totgllj�g, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NO ll//
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
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 V 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 LV,4 341,
Bug and tar removers
Household cleansers, oven cleaners
White Copy-Health Department/ Canary Copy-Business
TOWN OF BARNSTABLE C MPLIANCE: C'LAss; 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body Shops
unsatisfactory- 4.Manufacturers
COMPANY O (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS d I An _S Class: 7.Miscellaneous
05klVi 11 e- MA. QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS I
Case lots Drums Above Tanks Underground
IN OUT IN OUT IN OUT #&gallons Age Test
Ftsc:line,Jet Fue )
Di sel, Ke a e, #2 (B)
waste
w motor oil(C) .
trans ission/hy/aulic
Synthet' Or anics:
degrease
Miscellaneous:
r I
DIS OSAI✓RECLAMATION REMARKS:
Sanitary Sewage �. Water Supply
O Town Sewer ePublic
14 On-site OPrivate
1-'3. Indoor Floor Drains YES NO
O Holding tank: MDC
O Catch basin/Dry well
O On-site system
-.14. Outdoor Surface drains:YES N0,y_ ORDERS:
Q Holding tank: MDC
O Catch basin/Dry well
O On-site system
Waste Transporter
Name of Hauler Destination Waste Product
YES NO
Pers nterviewe Inspector Date