HomeMy WebLinkAbout2019 Jan 04 - Aquifer Protection Bylaw; Haz Mat Check Off0
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o� Ygr4 TOWN OF YARMOUTH BUILDING DEPARTMENT
SS{ APPLICATION FOR DETERMINATION OF NON -APPLICABILITY
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AOUIFER PROTECTION BYLAW §406.5.1.1
IM/19
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Applicant/Business Name:_'-
Property Owner: U -s 0, C rS L t
Property location: ► 1 cat. i 4 Unit#_Map&Lot#
Proposed Use: TrJ i Q S G) o Q
Has applicant has fully complied with the Submittal Requirements of §406.5.2 ?
(Attach copy of Hazardous Materials List)
2. Does the proposed use meet all of the Design and Operation requirements of §406.5.7,
3. Are the chemicals, pesticides, fuels and other potentially toxic or hazardous materials used or
stored at the site, or produced by the proposed use, in qualities not greater than those
commonly associated with normal household use,
4. Does the proposed use meet all of the objectives and water quality criteria of the bylaw:
The above applicant hereby acknowledges that the Building Inspector may require the applicant to submit the
matter to the Health Agent or Board of Health, and may require the applicant to demonstrate that he/she has
received a favorable report from the Health Agent or Board of Health. The Determination, if made, shall apply
only to the individual applicant and proposed use and shall automatically expire upon any change of use or
transfer of ownership of the business. There shall be no appeal from an unfavorable Determination of any such
application, nor from a failure to act, except for filing by the applicant for a Special Permit from the Board of
Appeals as otherwise provided herein.
ERMINATION: The Building Inspector, based upon a review of this application and information
supple d by the A ant, hereby,determines that the proposed use satisfies the requirements of§406.5.1.1 and
that th Appli n , ed not a for a Special Permit under §406.5
Building Ins Date Health Agent Date
Form must be fled with the Town Clerk and copies of this form must be sent to the following
departments (as listed in §406.5.4); Water, Engineering, Fire, Health, Planning, Conservation, Board of
Appeals.
Aquifer Protection District Waiver 05/08
TO: Commercial Applicants in the APD
FROM: Yarmouth Health Department
SUBJECT: Hazardous Materials
As pert of the application process for a Board of Appeals hearing or Determination of Non -Applicability,
please complete this form and return it with your applicatiom For fiuther information concerning hazardous
materials regulations, contact the Health Department Office.
. ,X, w.n.u611 va yuur Pfcaum anwor proposea Dusmess, ao you store, use, generate any of the
following types of products? Please check all which apply and fist gaandtks.
Antifreeze, Engine & Radiator Flushes
Hydraulic, Brake, Automatic Trans. Fluid
Grease, Lubricants
Floor/Driveway Degreaser
Rustproofing/Undercoating
Vehicle Waxes, Polishes
Paint, Vamrshes, Stains, Dyes, Thinners
Dry Cleaning Solvents, Carbon Tetrachloride
Other Cleaning Solvents
Drain, Toilet, Cesspool Cleaners
Bug dt Tar Removers
Printing Inks dt Dyes
Pesticides, Insecticides, Herbicides
Nitrate Fertilizer
Leather Dyes
Motor Oil
Gasoline/Fuels
/Cleaners
Battery Acid
Vehicle Detergents
Asphalt, Tar, Sealers
Wood Preservatives
Floor/Furniture Strippers —
Rock salt, Road salt
Refrigerants
Photo chemicals
Pool Chlorine
Rodenticide, Fungicides
Jewelry Cleaner
PCB=s
Electroplating Sludges g Others (List)
Applicant Signature: �l-/U- Date: 4
I IEALTAPDDETER 10-99