HomeMy WebLinkAbout0004 OLD STAGE ROAD - Health 4 Old Stage Road
Centerville.. P
A = 208 043
UPCV534 '
_ SEWAGE INSPECTIONS
DATE
LOCATION
VILLAGE &IZOIW - pASSESSOR'S MAP & LOT
-INSFkECTOR
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)
11 �'�� (size)
NO. OF BEDROOMS T
BUILDER OR OWNER
OWNER MAILING ADDRESS
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DATE :9/30/02
PROPERTY ADDRESS: 4 Old Stage-Road_ -� �
-- Centerville,Mass
02632
------------------------
RECEIVED
On the above date, I inspected the septic system at the above ad®fss,2 2002
This system consists of the following:
TOWN OF BARNSTABLE
1 . 1 -1500 gallon septic tank. HEALTH DEFT.
2. 1 -Distribution box.
3. 2-1000 gallon precast leaching pits. ( 6 ' X9 ' ) MAP ..__ t
Based on my inspection, I certify the following conditions: PARCEL , ®y�
4. This is a title five septic system. ( 78 Code )
5. The septic system is in proper working order at the present ti
6. Both of the laeching pits are presently dry.
SIGN /ATUR :
Name:— J .— P . —Macomber—jr .
Corll.pany :Jostab- Pam_ Macomber — Son, Inc .
Address :__Box
__Cen���yill�,_b��_Q2632-0066
Phone :--508- 775- 3338
-------------------
1
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775-6412
Ir
•
i
,per
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL. PROTECTION
TITLE 5
OFFICIAL, INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 4 Old Stage Road
Centervi e,Mass. 32
Owner's Name: Marcia R. Herington
Owner's Address: 382 Main Street
CPnt-Prvi11P,Mass_ 02632
Date of Inspection:a/30 f 02
Name of Inspector: (please print) Joseph P,Macomber Jr.
Company Name: Box 66
Mailing AddressCPnt-Prvi 1 1 P�Mass_ 02632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is mie. accurate and complete as of the time of the inspection. The inspection was performed based on my
trainine and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
Passes '
_ Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
_ Fails n
Inspector's Signature: K b Date: ����'ag
The system inspector shall�/ubmit a copy of this inspection report to the Approving Authority(Board of Health or
DEP) within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
—*This report only describes conditions at the time of inspection and under the conditions of use at that
` time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 4 Old Stage Road
Centervi e,Mass.
Owner:Marcia R. Herington
Date of Inspection: 9/3 0/0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. S=Passes.:
Ale have not found any information hich indicates that any of the failure criteria described in 310 CmR
15.303 or m 3� 10 Civ '15.30 exist. Any failure criteria not evaluated are indicated below.
Comments: •
The Septic system is in proper working order
at the preGPnt time
z
B. System Conditionally Passes:
VO One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined" please
explain.
X6 The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
No Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
I
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 4 Old Stage Raod
Centerville,Mass. 02632
Owner:Marcia R. Herinaton
Date of Inspection: 9/30/02
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
, e Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health,safety and environment:
A The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
A6 The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
• The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
.�The system has a septic tank and SAS and the SAS is less than 1l0�0 eet but 50 eet or more from a
private water supple well". Method used to determine distance _�
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:4 Old Stage Road
Centerville,Mass. 02632
Owner: Marcia R. Herington
Date of Inspection: 9/30/02
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or"no" to each of the following for all inspections:
Yes N
_ ackup of sewage in'to facility m or syste component due to overloaded or clogged SAS or cesspool
ZDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
/cesspool , o moo,,A t'avx 7
squid depth in eess.pcal is less than 6" below invert or available volume is less than '/, day now
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
�e1f times pumped �.
_ 4/ y portion of the SAS, cesspool or privy is below high ground water elevation.
`•epo-tio i of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
supply.
ny portion of a cesspool or privy is within a Zone I of a public well.
e '\• portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form,)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gPd
You must indicate either"yes" or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
`es no�
// the system is within 400 feet of a surface drinking water supply
?�the system is within 200 feet of a tributary to a surface drinking water supply
IV/the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — 1WPA) or a mapped
Zone 11 of a public water supply well
_ If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
eves" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15 304 The system owner should contact the appropriate regional office of the Department.
I
4
Page S of I I
R VOLUNTARY
OFFICIAL INSPECTION
O CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
NTS
SUBSURFACE
PART B
CHECKLIST
Properry Address:4 Old Staqe Road
enterville MaGc n2632
Owner:Mg, a R, uArington
Date of lospectioo:
Check if the following have been done. You must indicate ' s" or"no" as to each of the following:
Yes No /
_ / Pumping information was provided by the owner, occupant, or Board of Health
_ _Were any of the system components pumped out in the previous two weeks '
_ >;/ Has the system received normal (lows in the previous two week period ?
ZHave large volumes of water been inrroduced to the system recently or as part of this inspection
Zwere as built plans of the system obtained and examined? (If they were not available note as
AZ _ Was the faciliry or dwelling inspected for signs of sewage back up
Z— 'Alas the site inspected for signs of break out
Were all system components, eluding the SAS, Located on site ?
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum '
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on
Yes no
xisting information. For example, a plan at the Board of Health.
Determined 0 the field (if any of the failure criteria related to Pan C is at issue approximation of dis=cc
Is unacceptable) (310 CMA 15.302(3)(b))
5 �
Page 6 of 1 1
OFFICIAL INSPECTION FORM —NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:4 Old Stage Road
en ervi e, ass. 02632
Owner: Marcia R. Herington
Date of Inspection: 9/3 0/0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):���Sid P4
Number of current residents:
Does residence have a garbage grinder(yes or no):A1 )
Is laundry on a separate sewage system,(yes or no):?� (if yes separate inspection required]
Laundry system inspected (yes or no): 85
Seasonal use: (yes or no):Xg'S
Water meter readings, ifavailable(last 2 years usage(gpd)): 2000-57, 000 gallons=156/17 GPD
Sump pump(yes or no): X. 2001 -46, 000 gallons=1 26. 03 GPD.
Last date of occupancy:a; A/
COMMERCIAL/INDUSTRIAL
Type of establishment: /l 4
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):"
Industrial waste holding tank present (yes or no): 41A
Non-sanitary waste discharged to the Title 5 s stem (yes or no): �
Water meter readings, if available: .(sj
Last date of occupancy/use: A)
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of informations/1 2/9 7 Pumped tank Maint.
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: gallons -- How was quantity pumped determined? y/Q
Reason for pumping: A/'Q
TYP OF SYSTEM
_Septic tank,distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
SShared system (yes or no)(if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
Wbted from syst m owner)
ight tank Attach a copy of the DEP approval
110)Other(describe):
Approximate age of all com o ents, date installed (if known)and source of information:
Were sewage odors detected'when arriving at the site(yes or no):-OCtl
6
Page 7ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS
SESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4 Old Stage Road
Centerville,Mass. 02632
Owner:Marcia R. Herington
Date of Inspection: 9 f 3 0/o 2
BUILDING SEWER(locate on site plan)
Depth below grade:—__��L
Materials of construction: . cast iron _40 PVC mother(explain):
Distance from private water supply well or suction line: M",,-
Comments (on condition of joints, venting, evidence of leakage, etc.):
Tni ntc ;;pear- tight No eyidenc6 BI leakage `Phe system is
vented through the house vents.
SEPTIC TANK: v(locate on site
i
Depth below grade: l'�'
Material of construction: _concrete &metalfibergl as s.�olyethylene
iUlbther(explain) dl)/¢
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):40(attach a copy of
certificate)
'l
Dimensions: �� �X�i�r'
Sludge depth:
Distance from top of s udge to bottom of outlet tee or baffle:
Scum thickness:
r
Distance from top of scum to top of outlet tee or baffle: .1,
Distance from bottom of scum to bottom of outlet tee or baffe �
How were dimensions determined:z6z?� � j�
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Pump the septic tank every 2-3 years. Inlet & outlet tees
are in place.The tank is structurally sound and shows no
evidence of leakage.Liquid level at the outlet invert is
fifty one i}}ches.
GREASE TRAHfIlrl '(locate on site plan)
Depth below grade:f,�
Material of construct ion:,LconcretWk)m eta W,—if fiberglass,,G�olyethylene.dri)other
(explain):
Dimensions: _dz":�
Scum thickness: 1 r _
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: �1y9
Date of last pumping: flw
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
_C�rPaca trap iS nni—present _
7
Page 8 of I I
OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4 Old Stage Road
_Cen ervi e, ass. 02632
Owner: Marcia R. Herincrton
Date of lospectioo: 9/30/02
TIGHT or HOLDING TANK.G&-/e(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: 'M
Material of consrruction:,?.H—concrete :�)4 metal,10 fiberglass4),4 Dolyethylene,&ZAother(explain):
Dimensio�:El
Capacirn. gallons
Desien Flog d—gallons/day
Alarm present (yes or no): A0
Alarm level. A14 Alarm in working order(yes or no):
Date of last pumping: M
Comments (condition of alarm and f)oa( switches, etc.):
Tight or holding tanks are no nt.
DISTRJBUTION BOX: y (if present must be opened)(locate on site plan)
Deptn of liquid level above outlet inven: Weep I
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Distribution box has two laterals.No evidence of solids
carryover.No evidence o ea age in o
PUMP CHA;YIBER45�)_Plocate on site plan)
Pumps in working order (yes or no): _
Alarms in working order (yes or no): _
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump r-ha
not resent.
8
Page 9 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): t/(locate on site plan,excavation not required)
2-1000 gallon prpcact lacer-hing it- , ( 6 'X9 ' )
If SAS not located explain why:
Located: See page 10
Type
t/ leaching pits, number:
420 leaching chambers, number: P9
leaching galleries,number: O
-Tleaching trenches,number, length: 0
eaching fields,number, dimensions:
A)Ooverflow cesspool,number: -
-429movative/alternative system Type/name of technology:f 7,� �J1e, C 77p�'
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to medium fine sand No signs of hVdratLLi r- fail iirp
or ponding Vpgptation is nnrma
CESSPOOLS4OM-(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: (�
Depth—top of liquid to inlet invert: �A
Depth of solids layer:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no)
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Cesspools are not nrp4pni-
PRIVY (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids: _
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Privy iS not Drpsgnt-
9
pair 10o( li
OFFIC'LA1 INSPECTION FORM — NOT FOR VOLUNTALRY ASSESSMEN-S
SUBSURFACE SEWACE DISPOSAJ.., SYSTEM INSPECTION FORM
PART C
SYSTEM 'N PO RMATI ON (cominvco)
p,op,rr� A00f(114 Old Stage ROad
en ervi . 02632
O—<<Marcia eri
�i of nip„uoo: 9L3 07 02
5X—ITCH OF SCWACC DISPOSAL SYSTCM
Ao"o, i itci,t, of,hi i,..i I, Ciipoi,l )yii,m Incivding Ilc� 10 tl I<11t tivp permincnl rcf<rcnc< I+•nCm,ia, ,
..,,n,n 100 (((1, LQc,i, wjl,r( pvblic wilt, ivpply tnitr, i)( bviloin(
•
nag ><)
0
1 LL
I c:�
I �
aq�
� U
� o
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10
Page l l of l 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4 Old Stage Road
Centerville,Mass. 02632
Owner: Marcia R. Herington
Date of Inspection: 9/3 0/0 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-if checked,date of design plan reviewed: NO
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: AV
yE,c,_Checked with local excavators, installers-(attach documentation)
yg&_Accessed USGS database-explain: http: //town.barnstable.ma.US.
You must describe how you established the high ground water elevation:
Used: Gahrety & Miller Model 12/16/94 Grnnnrl water elevations abn'ue
sea level
Used: USGS: Observation well data Pnr ,ji,ne t-A92
Used: USGS; T hnirN, _Bnl l eti n 92_00A1 Plate 92 Anntta] ranges ef--greund
roun water elevations.January 1992
Leaching
Pit ,'eet
e'
Groundwater Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the botto
Of the leaching pit and the adjusted groundwater table is
feet.
r
11
`+•mnnrrntsr^•rr •rrrmr•ntstm+nxs:•rrr..r.:-.�+•+erm:�rrre+•mn nr�-as.raanr.at ^.. ��^�,r'..--.r..,t
1 TOWN OF Barnstable WARD OF HEALTH �
SUBSURFACE ,9F.WA(;F DISR)SAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
.•••r••t^r••.••.. —r.ir.^.--•+•.r.r.n•rt.rn r��.r.rrrarrr•'r—•.�rts+r-i arnmr—'rn*rr�ersr'vmrsi+�srs �n��ty.'��•. {I
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 4 Old Stage Road Centerville,Mass. 02632
ASSESSORS MAP , BLOCK AND PARCEL # 208-043
OWNER' s NAME Marcia R. Iferinaton
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAMEJ.P.Macomber & Son Inc ''`
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or City State I1T
COMPANY TELEPHONE (508 ) 775 - 3338 FAX (508 790 -1578
rs ,
CERTIFICATION STATEMENT
I certifythat I have
personally inspected the sewage diaposa� system at
this address and that the information reported is true , accurate , and
omplete as of the time of :inspection . The inspection was as performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
icone :
d System PASSED
The inspection «hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
f1e.Rlth or the environment as defined in 310 CMR 16 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have conducted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signature Date
...—.TZ•�.i—.� T
ne copy of this rt.ification must be provided to the OWNER, the BUYER
( where applicable ) and the I30ARD OF IIEAL7'II,
' I
* It the inspection FAILED, the owner or'"operator shall upgrade ' the system
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CPjR 16 , 305 ,
partd .doc
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
Jul 20 04 i75: 09p R. W. Glaser 1508,7759974 p. 2
a
s
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LOT t,
a LOT
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T C
DATE: -
Dy
HEREBY CE. - - - _ IS C ALEvp
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SHOWN ON ,i] _ :Iy.a4 1 ' t ��'�v s tt ��
A N J PAUL
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�i DOES !1`V 1—I rYa.. _ - -� 1.� a.'i. � .!`; *� lt,:�` �'��.�� 1 t�, _•;`Ti��� :',.
RP,EA AS SHOWNGti THE h IL^
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