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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
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NAME OF FIRM: cAp
MAILING ADDRESS: #4/V yj4xM o yAd�r�`� � o zo o '•F�
TELEPHONE NUMBER: ">7.s�-O&® a
CONTACT PERSON: oyAr CT Al-
Does your firm store any of the toxic or hazardous material 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 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: Ala
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determiggned 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:
Antifreeze (for gasline or coolant systems) Refrigerants
Automatic transmission fluid V Pesticides (insecticides,
Engine and Radiator flushes herbicides,rodenticides)
Hydraulic fluid (including brake fluid)
Photochemicals
Motor oils/waste oils --- i
asol ine, Jet fuel v►�� ` Mj i'D�9 Printing Ink
Diesel fuel Wood preservatives
' Kerosene # heating 0 "
Q n� (creosote)
Other petroleum products: grease �h, t�
lubricants �jO09 Swimming Pool chlorine
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)
Spot removers & cleaning fluids which you feel may be
(dry cleaners) K E C EI V E ® toxic or hazardous (please
HEALTH DEPT. list)
Other cleaning solvents
TOWN OF BARNSTABLE
Bug and tar removers
Household cleansers, oven cleaners
Drain cleaners
Toilet cleaners
Cesspool cleaners MAY 1 4 1981
Disinfectants
Road Salt (Halite)
. • • TOWN OF BARNSTABLE
BOARD OF HEALTH
CONTROL OF TOXIC AND HAZARDOUS MATERIALS - INSPECTION SHEET
FIRM CA h e f- �_ '
ADDRESSYa R�J_,
i
Major types of materials: 1) � ( 2) �T�5��11' 3)
4) AmendS) 6)
I. Description of material(s) use: Any-larA-C',
II. Storage (denote product by number listed above)
A. Containers metal glass paper plastic
cans,bottles,jars
drums,barrels
aboveground tanks
underground tanks
bags,boxes
open,loose,uncovered
inadequate labelling
B. Storage Facility V/or # Remarks/Recommendations
1. Indoor
a) separate, contained room + lockeir., -
b) stored in general work area
i) inadequate ventilation
ii) floor drains wif
iii) inadequate fire protection
2. Outdoor ;rs 15 P,p7+3
a) uncovered, exposed to weather r
b) pervious surface/catch basins ' VJ(, S P ,r-
j III. Disposalcwker
A. Reclamation/Recycling unit
B. On-site disposal by I
1. Town sewer
2. Regular septic system
3. Separate holding tank
C. . Off-site disposal
1, hauled by own firm
2, hired hauler
a) name of hauler
b) address or disposal site
Person(s) . Interviewed _ _ __ _ _ _ _ Inspector
Date - - - - ��C== � - - - -