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Home My WebLink About0519 YARMOUTH ROAD - HAZMAT A 61)p qy- r - � Number Fee 1126 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that WILLOW STREET MOTORS 519 YARMOUTH ROAD, HYANNIS, MA .----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. --------------------------------------------------------------•..................---...------............--------....------------------------------......--------... Restrictions: .----............................................................................................................................................................... This license is granted in conformity with the Statutes and ordinances relating there to, and expires 06/30/2021 unless sooner suspended or revoked. ---------------------------------------- JOHN NORMAN DONALD A.GUADAGNOLI,M.D. 07/01/2020 PAUL J.CANNIFF,D.M.D. THOMAS A.MCKEAN, R.S.,CHO Director of Public Health ta, J � Town of Barnstable Inspectional Services BARNSTABL,E -O�EMLC-Isp MA&E Public Health Division 1639�g4 1 Thomas McKean, DirectorMAML ,, � c .`� 200 Main Street, Hyannis,MA 02601 "' Office: 508-862-4644 Fax: 508-790-6304 } APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS t IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS DULY 1st—JLJNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 _ - CATEGORY,2 PERMIT-111 49.9 Gallons: $125.00_ RVS CATEGORY 3 PERMIT 500 or more Gallons:- $150.00 ❑ *A late charge of$10.00 will be assessed if payingnt is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL?_YYES_NO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF • GREATER THAN HOUSEHOLD QU TIES(25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: 0:3 V 's 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: 8. TELEPHONE NUMBER OF ESTABLISHMENT: CS 9. EMAIL ADDRESS: I 10. SOLEOWNER: Z YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE'#: COMPANY ADDRESS EMAIL: A JjV,44 SIGNATURE OF APPLICANT DATE 402 Q:\Application Fonns\Haz Mat Appli Draft Jan20l9.docx Number Fee 1126 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that WILLOW STREET MOTORS 519 YARMOUTH ROAD, HYANNIS, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2020 unless sooner suspended or revoked. PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI, M.D. 07/01/2019 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health (40 • • Town of Barnstable THE Inspectional Services BARNSTABLE OF T[L_ wnnwsrnea=_•ca+ra:ri-cman.rYunr- �� Public Health Division O i:,s-2aia Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 �.L Office: 508-862-4644 Fax: 508-790-6304ei X APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1st—JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 xv Gh CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ � -- *A late charize of$10.00 will be assessed if payment is not received by July Ist. 1. ASSESSOR'S MAP AND PARCEL NO. 31Y-o83 2. IS THIS A PERMIT RENEWAL?_YES_NO. IF YES, SKIP QUESTION 3. 3: FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUAN oxev-k (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: 8. TELEPHONE NUM 3ER OF ESTABLISHMENT: �� '" '�7(- Zb 2-- 9. EMAIL ADDRESS: �� (Z.�� 1-�l . e-b el l 10. SOLEOWNER: YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: id 7 3 9 ! COMPANY ADDRESS EMAIL: s SIGNATURE OF APPLICANT DATE Q:\Applicatfon Forms\Haz Mat App Revised 09-10-18.docx Number Fee 1126 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that WILLOW STREET MOTORS 519 YARMO UTH ROAD, HYANNIS, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. ------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2019 unless sooner suspended or revoked. ---------------------------------------- PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2018 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health �a 24,K=W Y lwao B%rnsxable egof erv><ces Richard V. Scali,Director Public Health Division B ARN TABLE mow, w HABNSTABLE. « Thomas McKean Director MA & p )Ev 9. `0200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 all APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE '`i" HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, ' HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS DULY 1 st—JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 yw.s . CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charge of$10.00 will be assessed if myuient is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. ��: A K -Z, 2. IS THIS A PERMIT RENEWAL? Y YES_NO. IF YES,SHIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATE S STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTI S(25 GALLONS). YES NO. 4. FULL NAME OF APPLICANT: tl 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: 8. TELEPHONE NUMBER OF ESTABLISH fMENT: 9. EMAIL ADDRESS: 10. SOLEOWNER: 4ES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: 3.j COMPANY ADDRESS EMAIL: ,.L SIGNATURE OF APPLICANT DATE < r Q\Application FormMAZMAT APP 2017 REVISED.docx Number Fee 1126 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable. Board of Health This is to Certify that WILLOW STREET MOTORS 519 YARMOUTH ROAD, HYANNIS, MA Is Hereby Granted a License For: Storing or Handling 111 -499 gallons of Hazardous Materials. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- ----------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2018 unless sooner suspended or revoked. ------------------------------ PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2017 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health .0 • " wwl1�. of B nstable o P �egulatorySemces BIKE� Richard V. Scali, Director Public Health Division BARNSTAB11 an.aqyy i • eaWw Abl-• fERVI�•CONK•HY-JS dlFu • °ARN��LE. ' Thomas McKean, Director ;OXS MILL;•O39-2LLE•PTsl R4?4;IaeE 1639.2014 39.(s 200 Main Street, Hyannis,MA 02601 5775 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE tt HAZARDOUS MATERIALS 0 IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, ' HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st-JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26- 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 -499 Gallons: $125.00 CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. � 2. IS THIS A PERMIT RENEWAL? YES_NO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS • ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANT11lTIES (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: t 1b12�- 1 5. NAME OF ESTABLISHMENT: �1 `� � -� 1�1��yu 6. ADDRESS OF ESTABLISHMENT: kj r . d 2la$r 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: S. TELEPHONE NUMBER OF ESTABLISHMENT: 5 0 ,r • 77 1 '©21� . 9. EMAIL ADDRESS: 61 l-36!�a;-Q ZZ c,�VM 10. SOLEOWNER:X_YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICAN DATE % ,/,7 QAApplication Forms\HAZMAT APP 2017 REVISED.docx Number Fee 1126 THE COMMONWEALTH OF MASSACHUSETTS $125.00 a Town of Barnstable Board of Health This is to Certify that WILLOW STREET MOTORS 519 YARMOUTH ROAD, HYANNIS, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. -------------------------------------------------------------------------- ---------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2017 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 07/01/2016 JUNICHI SAWAYANAGI THOMAS A. MCKEAN,R.S.,CHO Director of Public Health tw Town of Barnstable �t r Regulatory Services ° Richard V. Scali,Director " Public Health Division BABSTABLE y 1639 39 �0� B"Bwnasos uosa"niCDvs ea"nnsme ' RFD 's°i Thomas McKean, Director " ��` c 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 GG APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE.WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS DULY 1st—JUNE 3Oth). ` APPLICATION FEES CATEGORY I PERMIT 26— 110 Gallons: $ 50.00 .1 i CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ A late charge of$10.00 will be assessed if payment is not received by July 1st. ASSESSORS MAP AND PARCEL NO. DATE k, FULL NAME OF APPLIC-ANT: e NAME OF ESTABLISHMENT: 64 ADDRESS OF ESTABLISHMENT: Sl °tf +�VAkf&f 1( 624pC/ MAILING ADDRESS(IF DIFFERENT): TELEPHONE NUMBER OF ESTABLISHMENT: $' r ' 6>6 EMAIL ADDRESS: — 1t SOLE OWNER: K,YES No IF NO,NAME OF PARTNER: FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT TREASURER CLERK IF PREPARED BY OUTSIDE PARTY: SIGNATURE OF APPLICANT Name: Company Address Telephone#: Email: QApplication Forms\HAZZAPP Rev16.docx Page 1 of 2 i Town of Barnstable Office: 508-862-4644 Fax: 508-790-6304 Regulatory Services Department Public Health Division DAM MAW � Thomas A.McKean,CHO 200 Main Street, Hyannis,MA 02601 Payment Receipt ,Hazardous Materials Payment received: $125.00 (Check) on 6/17/2016 Permit number: 1126 ;Check number: 5983 Check amount: $125.00 Name on check: Willow Street Motors j I 1 Business: WILLOW STREET MOTORS Owner: GILBERT C .Address: 519 YARMOUTH ROAD, Hyannis ! ........ ...._.- ......... .. -------- .................. ......... __._ ._ ..._.... ........... _.........._ ... . ..__...._.. -- __._... V �\ Number Fee 1126 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that WILLOW STREET MOTORS 519 YARMOUTH ROAD, HYANNIS, MA Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- ------------------- ------------------------------------------------------------------------------ This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2016 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF, D.M.D. 07/01/2015 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health 4 • • w Town of Barnstable Regulatory Services Richard V. Scali,Director s r Public Health Division i63g6 ,e�' Thomas McKean,Director . V 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Application Fee: $100.0.0 ASSESSORS MAP AND PARCEL NO.3�� g DATE APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN III GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT NAME OF ESTABLISHMENT ADDRESS OF ESTABLISHMENT • TELEPHONE NUMBER o �- SOLE OWNER:_X ES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER CLERK • SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS /Z/v-10V;�2/.-,y&7t /y!4S/;,P('5 HOME TELEPHONE#_ Mcache\Temporary Intemet Fi1es\0LKD3\RAZAPP Rev2015.DOC v Town of Barnstable Office: 508-862-4644 v Fax: 508-790-6304 Regulatory Services Department BAIO EILF ; Public Health Division Thomas A.McKean,CHO 200 Main Street, Hyannis, MA 02601 Payment Receipt Mazardous Materials Payment received:$100.00 (Check) on 6/15/2015� jCheck number: 5611 Check amount: $100.00 Name on check: Willow Street Motors I Business: Willow Street Motors Owner: GILBERT C WOOD 'Address: 519 YARMOUTH ROAD, Hyannis I 1 • Number Fee 1126 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that WILLOW STREET MOTORS 519 YARMOUTH ROAD, HYANNIS, MA Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. ---------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 6/30/2015 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 6/30/2014 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable °FTHE ro,,� Regulatory Services Richard V. Scali, Director a s MA,%.LE, Public Health Division • 1639 �� ArEo 39 Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO. 3 h DATE APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN III GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT 01� NAME OF ESTABLISHMENT ADDRESS OF ESTABLISHMENT !�17 19 TELEPHONE NUMBER 4 g 17 j- yd 2 SOLE OWNER: Y YES, NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER CLERK AJ � 1 SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS ✓,Z /�'9, /l/�NLti2 L N �rS ®��f 9 HOME TELEPHONE# Q\Application FormsEAZAPP.DOC MAIL-IN REQUESTS Please mail the completed application form to the address below. Also include a copy of your contingency plan (to handle hazardous waste spills, etc). In addition, please include the required fee of$100. Make check payable to: Town of Barnstable. Allow five to seven (7) working days for in- house processing. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 FOR FAXED REQUESTS Our fax number is (508) 790-6304. Please fax a completed application form. Also, please fax us a copy of your contingency plan (to handle hazardous waste spills, etc). In addition, please mail the required fee amount of$100.00. Please make.the check payable to: Town of Barnstable. The check must be mailed to the address listed above. Allow up to four days for in-house processing. For further assistance on any item above, call (508) 862-4644 Back to Main Public Health Division Page 1 Q\Application Forms\HAZAPP.DOC Number Fee 1126 THE COMMONWEALTH OF MASSACHUSETTS $1oo.00 Town of Barnstable Board of Health This is to Certify that WILLOW STREET MOTORS 519 YARMOUTH ROAD, HYANNIS,MA 02601 Is Hereby Granted a License M� FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. -------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 6/30/2014 unless sooner suspended or revoked. --------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 3/12/2014 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health Town of Barnstable Barnstable Regulatory Services Department AlAnwdcaCity .ARN tom. Public Health Division I i639• 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO. _ /4'L 1 /693DATE APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN III GALLONS OF'HAZARDOUS MATERIALS FULL NAME OF APPLICANT �- ((P NAME OF ESTABLISHMENT 1 c ADDRESS OF ESTABLISHMENT ti ! f L (�• D�� I TELEPHONE NUMBER •7� 6 Z d �— SOLE OWNER:-ZYES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRES� OF AM O PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NOS.. r, STATE OF INCORPORATION FULL NAME AND HOME ADDRESS OF: PRESIDENT TREASURER CLERK SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS [Z,� 1\`6V7-t HOME TELEPHONE# J:\inspection handouts\Haz Mat Application2008.DOC s MAIL-IN REQUESTS Please mail the completed application form to the address below. Also include a copy of your contingency plan (to handle hazardous waste spills, etc.) In addition, please include the required fee of$100. Make check payable to: Town of Barnstable. Allow time for in-house processing. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis,MA 02601 FOR FAXED REQUESTS Our fax number is (508) 790-6304. Please fax a completed application form. Also, please fax us a copy of your contingency plan (to handle hazardous waste spills, etc.) In addition, please mail the required fee of$100. Please make the check payable to: Town of Barnstable. The check must be mailed to the address listed above. Allow time for in- house processing. For further assistance on any item above, call (508) 862-4644 Back to Main Public Health Division Page JAinspection handouts\Haz Mat Application200800C SPILL CONTINGENCE' PLAN i U Emergency Coordinator, Name: Address: -gyp v c� 6-2-�1 Daytime Phone: !—Q< f=.7,5 7, -fS - ! 2 Evening Phone: t Fire Department: Barnstable Public Health Division: 508-862-4644 DEP 24 Hour Spill Hot Line: 888-304-1133 Waste Hauler: Name: c Phone: Building diagram indicating hazardous material/waste storage area, location of absorbent scavenger materials, fire extinguishers, fire alarms (if present), and evacuation route (if applicable). Actions to be taken to control a spill or release, and preventing it from reaching a catch basin, sewer system or the ground. jj I `°pTME TOk4 Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 9 BARMASSBLE. ' 200 Main Street• Hyannis, MA 02601 �p 039.6. rFD MP'� TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: — V ( Date:—Wsqq Location/Mailing Address: Warm 15 Contact Name/Phone: 7 _ " Invento Total Amount: qJ SDS: License#: Tier II NO Labeling: C Spill Plan e Oil/WaterSeparator: UC-) Floor Drains: Emergency Numbers: Storage Areas/Tanks: Emergency/Containment Equipment: CO MO Waste Generator ID: Waste Product: Date&Amount of Last Shipment/Frequency: NtiA Licensed Waste Hauler&Destination: Other Waste Disposal Methods: Bof S' WcT�r to LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) V Windshield wash Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants iscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) ustproofers Photochemicals(Developer) Car wash detergents /® Printing ink Car waxes and polishes Wood preservatives (creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION RECOMMENDATIONS: ►` Inspector: Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS y°rIKE Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 9BARNSTABLE. MASS 200 Main Street• Hyannis, MA 02601 . A i639 M TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT rE0 A'S Business Name: �t I o,,J S*• A o$ Date: y Location/Mailing Address: S'1 4vaA-VI, 5 Contact Name/Phone: olo 77 I- 0?-o2- Inventory Total Amount: SIDS: DvL -I,wt. a.G"55 License#: t t2-(01 Ch+ 1 Tier II : Q1 o Labeling: 0K Spill Plan: 1-wta.-tSk�J Oi[/Water Separator: 01A Floor Drains: n10 Emergency Numbers: 0-k< Storage Areas/Tanks: 0,1 <,J, Emergency/Containment E i ment: R u- S I i aQc� Waste Generator ID: W ste Product: Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: 1.�k.6Ve-- 01 -e ACA- yr I&XV1 LIST OF TOXIC AND HAZARDOUS MATERIALS 1V p D�AWY- I ti 1 v1 � �iv1, t,t Aek�v,ti e">/ . NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardouslaterial use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid �L Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) ✓ Windshield wash Motor oils +r Wa9�o-, ✓ Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) �— Car wash detergents Printing ink �- Car waxes and polishes Wood preservatives (creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners V Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECOMMENDATIONS: &5 i Inspector Facility Representative: WHITE COPY- HEALTH DEPARTMENT/CANARY COPY- BUSINESS i pf IME►oh, Town of Barnstable Office:508-862-4644 it Public Health Division Fax:508-790-6304 BAR MASS. E. ` 200 Main Street• Hyannis, MA 02601 MASS i639 'e� TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT RFD MP'�s Business Name: 01 1 ID445 - Im o't-o f5 Date: y Z i' /(o Location/Mailin Address: 5,9 r a Contact Name/Phone: Inventory Total Amount: " MSDS: OTC- I w-w, License#: 119 o Tier II : MA Labeling: S3�P.elto kaw Spill Plan: UK Oil/Water Separator: Floor Drains: !,,�o Emergency Numbers: 6Y-, Storage Areas/Tanks: Ake I(ea rl Ll a a,�.�-�, 2 - H G AJ Cow`�a S CO rc•Gl�r> S . Emergency/Containment Eq ipment: x 5 Waste Generator ID: Waste Product: Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: 04-9ki- t +cavy -r••4 �-o D41,&t �D,>«- -k LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield wash I Motor oils Miscellaneous Corrosives a Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents f S Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Z Lacquer thinners Z �� Miscellaneous Combustible z Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil&stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, q 1 hydrochloric acid, other acids) VIOLATIONS: W k4 qe, ,L y OA90ye kkk a- ORDERS: �L o�7 0. Q P�12L`-1oVL, -C �551 be 0-r r2 coKd& INFORMATION/RECOMMENDATIONS: Inspector: Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS °F THE ro�y'ti Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 • BARMAq .9• 200 Main Street• Hyannis, MA 02601 �'0'FOMn+° TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: 0,11 o V3 6+- AAc,+. -5 Date: 7 3a I S Location/Mailing Address: R a�vvLo.A-L- aKV%15 Contact Name/Phone: �Q_^T ca�A , E �� y�e c S Syg _-7-71_ 0202- Invento Total Amount: ^'1 � MSDS: o _ License#: (� Tier II : o Labeling: Spill Plan: No Oil/WaterSeparator: QV Floor Drains: Emergency Numbers: Storage Areas/Tanks: � 4 ra�"`7j 1a t1'rfx k, C �� Q� •►cis Emergency/Containment Equip ent: v-a A!!'ot vA\ l t Waste Generator ID: tJ00-1, Waste Product: Date&Amount of Last Shipment/Frequencx: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: A 1 LIST OF TOXIC AND HAZARDOUS MATERIALS N o A10-I or ( CLM,).s � �iy« las•I- „one c�-,oy� NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous maenal use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. / Antifreeze Dry cleaning fluids Automatic transmission fluid �— Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield wash S�k� Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives (creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda �— Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: 05 0 % e—• 0 4 COwk, ORDERS: ! J D11k pkqW C vU� VwI�A.0 C INFORM TION/R COMMENDATIONS: , + - Inspector: I I� Facility Representative: r� WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: � 12o l l q TOWN OF BARNSTABLE � TOXIC AND HAZARDOUS MATERIALS REIGPSOMPON FORM NAME OF BUSINESS: -60 5J-. OA ehr5 BUSINESS LOCATION: 5'l q Y46MO,23Laytvt,5 INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER:Jn� �� 1 42b 2r 12 CONTACT PERSON: �1_ �II,C. EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: \)�c S t- �10 INFORMATION / RECOMMENDATIONS: 5 *a ocb s 6A I d Fire District: D( 199 n \& -je t,0A jpd,2 e" cty%v%t S Ntj,JL -�ooyt \,Ge,.nS.� 5 D,ll p�ar� Waste Transportation: " Last shipment of hazardous waste: Name of Hauler: o�W kIA-- o% — 6L;0<1&x. ►o ak1 Destination: Waste Product: oy,5,kt, Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum A I reeze or gasoline or coolant systems) O Miscellaneous Corrosive to �Q-1 7NEW I" ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages 1 D Wood preservatives(creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible %\D Car wash L detergents �55 �`� �C� S g y Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials /; Fn . ' •: -TOWN OF BARNSTABLE BOARD OF HEALTH • .ARTICLE Ili MINIMUM STANDARDS FOR HUMAN HABITATION Dale e. Y,Qwner , .. .: - ! Tenant . _ ......_... ._�__ Address ..._......_ om-Ilie once llii e' i or , IleUulatlon #: '. —11es —flo . Recommendatlons '; ,•.., ,. 2. Kllchen Facilities ' •• 3, ' Bathroom facilities ` _•••,.. ..4, W-lInr Supply, , .5.. Not Water Facilities • 6. Healing Facilities41 .'. 7•• Lighting and.Eleclrlai Facilities ' • � Venlilollon •, • , • � • ' ' 9. Inslail6lion and Maintenance of Facilities 40. Curialiment of Service 11. Space and Use 12. Exile , • 13. Installation and Maintenance of Structural . -•,' • Elements 14. Insects and Rodents . 15. Garbage and,Rubbish Storage and Disposal • '' i6. Swage Disposal ' 17.• Temporary Housing ' PART 11 . 37. . f lacarding of Condemned Dwellingl • .Removal of Occupanles Demolition . Person(s) Inlervlewed Inspector ._._........ If Public Building such as Store or Holel/Mole) specify here. _._._.. , :, .••.. .,.�YMMw,.�.d.•,M1rSN••r 1 :•w.a.3'�1•.r , .• -a�.l <i• . ..•. �j� 8� ('mac ,�.� - �3aB {�� r- t i I __ TOXIC AND HAZARDOUS MATERIALSJREGISTRATION FORM Mail To: NAME OF BUSINESS: Board of Health MAILING ADDRESS: „Z Town of Barnstable TELEPHONE NUMBER: `721 P.O. Box 534 CONTACT PERSON: Hyannis, MA 02601 /�v� �-E Does your firms re 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 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 in ap=pOW! 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 t,� Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil c--- 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 I✓/ 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 Y Spot removers & cleaning fluids be toxic or hazardous (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 satisfactory 3 Print B BOARD OF HEALTH ' . ody Shops 0 unsatisfactory- 4.Manufacturers COMPANY1 � � � (see"Orders") 5.Retail Stores —o-- 6.Fuel Suppliers ADDRESS lass: 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors; OUT-outdoors) MAJOR MATERIALS Case lots Drurns Above Tanks I Underground Tanks IN OUT IN OUT IN. OUT #&gallons 777 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: /d Q /4 6 DISPOSAURECIAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply - O Town Sewer Public O On-site OPrivate 3. Indoor Floor Drains YES-No L/ O Holding tank: MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO t/ ORDERS: O Holding tank:MDC O Catch basin/Dry well O On-site system 5. Waste Transporter DestinationName of Hauler YES NO 1. - 2. V f erson (s) Interviewed Inspector Date TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM Mail To: NAME OF BUSINESS: Board of Health MAILING ADDRESS: Town of Barnstable TELEPHONE NUMBER: P.O. Box 534 Hyannis, MA 02601 CONTACT PERSON: C�84-a b f,V�!4t_,*-7 W 6a, fl 7rA Gr� IN4 VA";- -761V 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 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 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 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 LI/ Road Salt (Halite) Gasoline, Jet fuel / Refrigerants Diesel fuel, kerosene, #2 heating oil y 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) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business .f TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair Q satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body shops 4 O unsatisfactory- 4.Manufacturers COMPANY �` (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS . Claw 7 7.Miscellaneous 'QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS , 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 ; ` a; ,, Miscellaneous: k R t DISPOSATJRECLAMATION REMARKS:1. Sanitary Sewage 2. Water Supply 57,0 -�',%s'�i`, O Town Sewer . OPublic "Q On-site QPrivate 3. Indoor Floor Drains YES -N0 t� $ O Holding tank: MDC , O'Catch basin/Dry well O On-site system t 4.Outdoor Surface drains:YES NO ORDERS: Q Holding tank:MDC O Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product 1 YES NO 2 �, . Y Person(s) Interviewed Inspector °Date"