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TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
Mail To:
NAME OF BUSINESS: rt" # Board of Health
MAILING ADDRESS: 0 h j A '4' 0e - /%W'W>7W Town of Barnstable
TELEPHONE NUMBER: 27 P.O. Box 534
CONTACT PERSON: OZ tld 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 Ions 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 '
Please put a check beside each product that you store:
I` Antifreeze (for gasoline or coolant systems) Drain cleaners
I/ Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
_ 14 Hydraulic fluid (including brake fluid) Disinfectants
1/ Motor oils/waste oils Road Salt (Halite)
_V Gasoline, JAI Refrigerants
V , 2 heating oil V Pesticides (insecticides, herbicides,
►�' Other petroleum products: grease, lubricants rodenticides)
L Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
V Battery acid (electrolyte) Wood preservatives (creosote) i
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
Paints, varnishes, 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 "Poiso/" 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
TOWN OF BARNSTABLE COMPL771 M CLASS: 1.Marine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body Shops
unsatisfactory- 4.Manufacturers
COMPANY�Lri>is?/dcr yi6aoL44-4Z (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS6Is� !m iv . J�fc`/ C18S5: 7.Miscellaneous
ZV^M� �$vUANTITIES AND STORAGE (IN=indoors;OUT=outdoors)
MAJOR MATERIALS Case lots Drums Above Tanks Underground Tanks
IN OUT IN OUT IN OUT #&gallons Age Test
1
Fuels:
Gasoline,JQt-F4e14X)
#2 (B)
Heavy Oils:
waste motor oil (C)
-----------------------
new motor oil (C) �•C'`d „�
transmission/hydraulic '
Synthetic Organics:
degreasers 14 e
Miscellaneous:
��ri°• �Lr � v �
VA 1017"L �~
Mee
DISPOS ECLAMATION REMARKS:
1. Sanitary Sewage 2.Water Supply
O Town Sewer Public
On-site QPrivate
3. Indoor Floor Drains YES NO
Q Holding tank. MDC
Q Catch basin/Dry well _
Q On-site system !/yf
4. Outdoor Surface drains:YES____NO ORDERS:
Q Holding tank:MDC
Q Catch basin/Dry well
O On-site system
tyl a4q '11 a[P/IJ `Tj•`�c%s�1•
5.Waste Transporter
Name of Hauler Destination Waste Product
YES 0
1. z
2.
� A
Person (s) Interviewed Inspector D to
TOWN OF BARNSTAB„LE COMPLIANCE: CA T: Marine,Gas Stations,Repai.r
t. 2. Printers
BOARD OF HEALTH O satisfactory 3. Auto Body Shops
unsatisfactory- 4. Manufacturers
��. 5, Retail Stores
COMPANY ,'—' 1lJ"" (see"Orders")
6. Fuel Suppliers
ADDRESS i�a�'�sY .f{,� -='t='"'"'"' Class: 7. Miscellaneous
QUANTITIES AND STORAGE (IN=indoors; OUT=outdoors)
Case lots Drums AboveTanks Underground Tanks
MAJOR MATERIALS IN MIT IN IOUT IN UT N gEllons A9e s ?
Fuels: ,
Gasoline, Jet Fuel (A)
Diesel, Kerosene, #2 (B)
Heavy Oils:
waste motor oil (C)
new motor oil. . (C) `
transmission/hydraulic �.
Synthetic Organics:
degreasers
MiscelL4neous; t
—� -
DISPOSAL RECLAMATION REW,RKS: N
1. Sanitary Sewage t
PP1Y
OTown Sewe V i ubli c c,✓rt, 1 �'
site Private
3. .Indoor Floor Drains: YES N07
O Holding tank: MDC -_ ; )n ( _. �-
O Catch basin/Dry well .fll`�✓`__ a"`:_ � -(�-:: t
On-site system
4. Outdoor Surface drains-.YES N i
O Holding;, tank: MDC Lis
OCatch basin/Dry well _ _`�__
OOn-site system
S. Waste Transporter Licensed?
Name f .flpstination g,1Ste`Product_ �Yps NO
. ^� :Y6
ei r e on s) I t.erviewed Inspector Date
YQW N OF BA R N STA B L E nCOMPLIANCEjOrders-3
CLASS: 1. Marine,Gas Stations,Repai.r
O-satisfact 2. Printers
'60ARD OF HEALTH 3. Auto Body Shops
O unsatisfa 4. Manufacturers
COMPANY Col-11416I)id �o(l (see" S. Retail Stores
—r---- 6. Fuel Suppliers
ADDRESS r Class: 7. Miscellaneous
QUANTITIES AND STORAGE (IN=indoors; OUT=outdoors)
MAJOR MA7ER ALS Case lots Drums AboveTanks Underground Tanks
IIN QUIT IIN IOUT IN IOUT Lyallons Aize rest?
Fuels:
Gasoline, Jet Fuel (A)
Diesel, Kerosene, #2 (B)
Heavy Oils: ;
waste motor oil (C) ! �
new motor oil (C)
transmission/hydraulic
Synthetic Organics:
Miscellaneous: 1
/5 olj) C)/41 roe✓'�ol/I
4 i y21iirl 6'f A 11✓t&t
DISPOSAL RECLAMATION REMARKS:
1. Sanitary Sewage 2. Water Supply
OTown Sewer o Pub t i c �- , -
O On-site Private/0/
✓ `
3. Indoor Floor Drains: YES NO ✓
O Holding tank: MDC
O Catch basin/Dry well
On-site system �-
4. Outdoor Surface drains-.YES NO
OHolding tank: MDC ----- ;
OCatch basin/Dry well _— .__---___._.
On-site system
S. Waste Transporter Licensed?
Name of HaUler Destination N stg Product YFS1 NO
2.
I
ei Pe son(s) Tnte -ie �� % Inspector Date
182 Marstons Awe.;Barnstable Y
A= Cumiriaquid Golf Course -
4
u II
J
� n
V
Q
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1. Marine,Gas Stations,Repair
BOARD OF HEALTH O satisfactory 3. Printers to Body Shops
unsatisfactory- 4. Manufacturers
COMPANY -�� O (see"Orders") 5. Retail Stores
6.Fuel Suppliers
ADDRESSTC" V44 y r1SwlaSS: a 7. Miscellaneous
� �o UANTITIES AND STORAGE (IN= indoors;OUT=outdoors)
MAJOR MATERIALSound Tank,
IN OUT IN OUT IN OUT #&gallons Age Test
Fue 5 A x
Gasoline Fuel (A)
D� ie_sel erosene, #2 (B) J"
Heavy Oils:
waste motor oil (C)
new motor oil(C)
transmission/hydraulic
Synthetic Organics:
degreasers
� rJ
Miscellaneous:
CU3
x
DISPOSALIRECLAMATION REMARKS:
1. Sanitary Sewage 2.Water Supply Rl `
O Town Sewer ' "`32 'ublic
ova; le
f�On-site OPrivate
3. Indoor Floor Drains YES NO_x_ \rJ i
O Holding tank:MDC ,
O Catch basin/Dry well L.
O On-site system �1
4. Outdoor Surface drains:YES NO._ ORDERS:
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
5.Waste Transporter
Name of Hauler Destin*ation Waste Product Licensed9
S NO
1. 2 ti� , \ -
,EPA MP v h
�. 9�ylux _
vPwe AM Interviewed Inspector Date
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