HomeMy WebLinkAbout2240 IYANNOUGH ROAD - HAZMAT 7
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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS:jfA& 663 Board of Health
MAILING ADDRESS: je,7- S '2, Town of Barnstable
TELEPHONE NUMBER: .S~®if` 3 vL/ 3/ P.O. Box 534
CONTACT PERSON: Phi f biV f 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 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 store
Please put a check beside each product that you store:
ii Antifreeze
i t eeze (for gasolene or coolant systems) /Drain cleaners
il Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) V/ Disinfectants
Motor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
Diesel fuel, 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
r0 Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
Paints, varnishes, stagy, d 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
VMetal 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
TOWN OF BARNSTABLE OMPLJANCE: CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body Shops
O unsatisfactory- 4.Manufacturers
COMPANYl' Gs�x�`'L (see"Orders") 5.Retail Stores
e 6.Fuel Suppliers
ADDRESS ass: / * 7.Miscellaneous
QUANTITI S AND STORAGE (IN= indoors; OUT=outdoors)
MAJOR MATERIALS Case lots 1Underground Tanks
A�A— # IN OUT IN OUT IN OUT #&gallons Age Test
Fuels: *_,��rz
Gasoline, 11b w /
Diesel, Kerosene, #2 (B)
Heavy Oils:
waste motor oil (C) �
new motor oil (C) '4 V
transmission/hydraulic
Synthetic Organics:
degreasers i9
slalllaneou : j ��✓
e
1 �
� � , 7
20tpk. Ii
DISPOS EC N REMARKS: )
1. Sanitary Sewage 2. Water Supply 4
O Town Sewer Public
�YOn-site OPrivate
3. Indoor Floor Drains YES_.!/NO
O.Holding tank:MDC 4rW
Catch basin/Dry well
O On-site system `
4. Outdoor Surface drains:YES f1NO ORDERS:
O Holding tank:MDC � 8@
Catch basin/Dry well ,�
O On-site system
5.Waste Transporter P�V&"� t
Name of Hauler Destination Waste Product
YES NO
2.
_�4t91�-- �.
Person w terview Inspector Date
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