HomeMy WebLinkAbout0091 CINDY LANE - Health 91 CINDY LANE, BARNSTABLE
A= Gregg' s Repair Ser.
Date:
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS:
BUSINESS LOCATION: IWAY L Q
MAILINGADDRESS: Mail To:
TELEPHONE NUMBER-6Board of Health
t� �—��� Town of Barnstable
CONTACT PERSON: c P.O. Box 534
EMERGENCY CONTACT TE EP NE NUMBER: Hyannis, MA 02601
TYPEOFBUSINESS: yll �q t7�ttey /d�r4.•
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own
use? YES L.� 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 character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
,a a&'"Antifreeze(for gasoline or coolant systems) Drain cleaners
✓NEW t/CJSED� � Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
�!Vils Ag) Pesticides
EW USED (insecticides, herbicides, rodenticides)
Ga_ soline. Jet Fuel r k 4:�) 1 Photochemicals (Fixers)
�•" Diesel fuel, kerosene, it f NEW USED
A" Other products:roducts: rease Photochemicals (Developer)1 '
P
lubricants, gem I NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preserva
tives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
Car waxes and polishes Leather dyes
Asphalt & roofing tar Fertilizers
Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers
Any other products with "poison" labels
Paint brush cleaners (including chloroform, formaldehyde,
Floor & furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel w
(including bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids �., � 4~0 ,1 M
(dry cleaners)
'• ��s•ll Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
• • • • Stations, •.
satisfactory 2.Printers
3.Auto Body Shops
pp�
4.Manufacturers
•
"Orders") 5.Retail Stores
7.Miscellaneous
off
• ' �, ,
G •
� • •
Case lots Drums' Above Tanks Underground Tanks'"
I MEN OVAIMISM
new motor
011 (csm) m 0
,. ,
�V1
10 0 1 M on
• 1 • . 11001M
MIEN
oil MINNIE
0 r921111,11s
ONIONEEM
0011001ME
. 010011000w�
;,y In
VIA
IN
. • I .. , A V ralmolfi lEef l lMimi PKAWN W—1V 4",OMO.
., /�� ►�fIT�1��11����
Name of Hauler Destination Waste Product Licensed?
r _.. _ _ ._ _ _. ... .. .... ...-� r .,.., .r ^"i..f-.-,. . \_ .�L;.. .. �4�1 .�'i.:v.•.''.. ....«+ , :�T c
TOWN OF BARNSTABLE - U'NI E-RGRD 7ND"f l'tEL—A-M-D=C:H,E I C L STORAGE REG I STRAT I ON
MAP N0,1. - J�""`"PARCELNO". .�.i
ADDRESS OF TANK: �` C INrDY 1, Ak6>llwl-r� VILLAGE:
MAILING ADDRESS ( IF D I FFERENTS FROM ABOVE Qy)( 17
1
OWNER NAME: Y`p �� �i�r PHONE:
-INSTALLATION DATE: 'o IcY BY:
T nISTALLER ADDRESS: � , w-r�c e C I�d CERT.NO.
*TANK LOCATION: n re�lyzj- -- 4 1- I^,�_rCy.P
C 0=00PR I OU TANK LOCATION W I TM RMORIECT TO =U I LD I Nm>
CAPACITY 7 TYPE OF TANK :AGE YRS-. FUEL/CHEMICAL
.TESTING CERTIFICATION [ ] PASS [ ] FAIL DATE
^ LEAK DETECTION [L']rCHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION [ } YES [ La-'NO DATE. TO BE REM VED
FIRE DEPT. PERMIT ISSUED CLA--YES C ] NO DATE / 0-3l0
k'
CONSERVATION [ LI-CHECK IF N/A DATE '-
-BOARD OF-' HEALTH TAG NOx" [ ]. DATE
# PLEASE PROVIDE A SKETCH SHOWING ,THE TANK LOCATION ON THE BACK OF THIS CARD
TOWN OF BARNSTABLE - U'NDERGROUND-FUE' L-AN-D-GHEM I CA-L,,.$TORAGi E REG I STRAT I QN
MAP NOz �PARCEL N0.
ADDRESS OF TANK: q1 �_������ . jf�' yf�AT
�r� VILLAGE: )t�A
Numbwr, e- I Obr.;t
MAILING ADDRESS ( IF DIFFERENT4FROM ABOVE) : Pe t3ex 17
OWNER NAME:
(mil `o��C 1• -, L' ,l i << PHONE:
(S_�r�13��
--
INSTALLATION DATE 5 �d c�b`� ' BY: '' `�f '��7_
_T �
INSTALLER ADDRESS: / jet t t � . CERT.NO.
*TANK LOCATION. !►g't, 4L
`• (0K00A2-Ot TANK LOCATION WITH AK;P7CT TO OUILD�INO)
• CAPACITY 7 TYPE OF TANK S'-IY~�'L AGE YRS. FUEL/CHEMICAL
" 3
•TESTING CERTIFICATION C ] PASS [ ] FAIL - DATE
LEAK DETECTION ELT CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION [ ] YES CLT] `NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED CV]lYES C 7 NO DATE
CONSERVATION E LT""CHECK IF .N/A DATE
BOARD. OF HEALTH TAG NO~ [ _ ] DATE
* PLEASE PROVIDE A SKETCH SHOWING THE TANK, LOCATION .ON THE BACK OF THIS CARD
971
l�
LL . �.
TOWN OF BARNSTABLE
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS
NAME o giv i
ADDRESS _ VILLAGE �a �
LOCATION OF TANK CAPACITY: TYPE OF FUEL AGE: TYPE:
OR CHEMICAL
r'
j
(Give same information for any additional tanks on reverse side of card)
DATE OF PURCHASE OF EACH: 1. 2. 3. 4.
DATE OF FIRE DEPARTMENT PERMIT: yp
TESTING CERTIFICATION SUBMITTED:
PASSED DID NOT PASS
S