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HomeMy WebLinkAbout0037 PINEVIEW DRIVE - Health 37 PINEVIEW DRIVE, C_'OTUIT A= 040 122 i. Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection 1Alllllun F.Wald Trudy Cox* owrHnw avow" Argao Paul Cellueol C Davld�B.�Struhs u•t ( 4 . lTVnlfl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,37 61J e o/,,ud 0/Z PART A CERTIFICATION h"r y F�,, �e�ye/' Property Address: Address of Owner. Date of Inspection: -- (If different) Name of Inspector. W.E. Robinson SR T�e✓ e st���-� Company Name.Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 8� passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: € Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,.if applicable and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A) �SYSS PASSES: , I have not found information which indicates that the m violates an any system y of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. Bl TEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection IndiK yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain wliy not) The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or exflitration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ! (revised 11/03/95) 1 One Wint*r Street a Boston,Massachusetts 02108 a FAX(617)SWI049 a Telephone(617)M-5500 ie'f Printed.on Recycled Paper SUBSURFACE SEWAGE_ DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3 7 1III e, o 7-4 e rzs t,�L Sf' 61,s Owner. Date of Inspection: _g (, ✓ Bl SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pear inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl THER 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 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. Z SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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. 3) O (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) -rhe astv"" .- Property Address: ' /14 ai2t�,�a Owner. 41 Date of Inspection: D). YSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.903. The basis for this determination is identified below. The,Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge 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. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day.flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy.is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate.nitrogen. El LARGE S STEM FAILS: following criteria apply to large systems in addition to the criteria above: system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public and safety and the environment because one or more of the following conditions exist: 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 supple' the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner r of any.such system shall bring the system and facility into Rill compliance with the groundwater treatment program requirements o 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for.further information.. . (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM PART B CHECKLIST e- e sin te- � .Sll a-n rt C.. �•�U I S Property Addrew`3 Owner. e i^ Date of Inspection:_9 Check if the following have been done: Pumping information was requested of the owner,occupant, and Board of Health. /None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large.volumes of water have not been introduced into the system recently or impart of this inspection. �As built plans have been obtained and examined. Note if they are not available with N/A. ✓The facility or dwelling was inspected for signs of sewage back-up. he system does not receive non-sanitary or industrial waste flow site was inspected for signs of breakout. system components,excluding,the Soil Absorption System, have been located on the site. septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. the facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3 7 /°r��v/� G-�l Co fcu Owner. ,rrrn pAvr 5 1/_ F/�i('e r�Q.�^ � Date of Inspection: s a-2—g Zo FLOW CONDITIONS RESIDENTIAL:- Design flow'_jj 0 gallons Number of bedrooms: 3 Number of current residents: (5 Garbage grinder(Yes or no):_iO Laundry connected to system or no):� Seasonal use(yes or no): Water meter readings,if available: Last date of occupancy: COMMERCIAL/INDUSTRIAU Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Lost date of occupancy: OTHER(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and ce of information: System pumped Wpart of inspection: (yes or no)_ If yes,volume pumped: gallons Reason for pumping: TYPE WSYSTEM a/ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yea or no) (if yes,attach previous inspection records,if any) Other(explain) ' APPROICIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no)Li rd (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C -7 ,p SYSTEM(INFORMATION(oontinued) Property Address: 3 / / il7C.UJC aR C�o�� ;rho- 951fle �0 Owner. ��/G�Q✓l��/' �'cc�.¢ma e_ 119�s Date of Inspection: � SEPTIC TANK v (locate on site plan) Depth below grade: /0 _ Material of construction:=Z�ncrete_metal_FRP—Other(explain) Dimensions Sludge depth: g ! Distance from top of sludge to bottom of outlet tee or baffle:3 Scum thickness: -3 ' I. Distance from top of scum to top of outlet tee or baffle: S Distance from bottom of scum to bottom of outlet tee or baffle: !b Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) ti i Cc-4 5 C r'N i G TRAP: (locate on ite plan) Depth be w grade: Mate ' of construction:_concrete_metal_FRP—other(explain) Dime Scum from top of scum to top of outlet tee or baffie: from bottom of scum to bottom of outlet tee or baffle: Co eats: (reco endation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evide of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 /1 n L 611 e-&1)aA Owner. Al `�C�'C r1�e/' s u3 4�ntl e. Date of Inspection: TIG OR HOLDING TANK: (locate site plan) _ — Depth grade: Material of —concrete metal_FRP—other(eplain) Dimensio Capacity: ns De�ige► ¢allona/day Alarm 1: Comments: (condition o islet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX— (locate(locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) A-e) PUMP C BER: (locate site plan) . Pumps' working order:(yea or no) Comoments: (note condi n of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address 3 /�rl l�/�.&') ,on C!f AGLt 7 7-he- 51,4�L v/ Owner. f, C/icxeh'f e s'' cSe�3 sh 4c S Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on the plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type leaching Pitt,number:--L leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Comments: (note condition of soil,e' of hydraulic failure,level of ponding, condition of vegetation,etc.) Z- P f a d CorOf CESSPOOLS:_ (locate on 'te plan) Number and afiguration: Depth•top of to inlet invert: Depth of solids yer. Depth of scum is r: Dimensions of pool: Materials of co n: Indication of water: inflow Cesspool must be pumped as part of inspection) Comments:(note udition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY:_ (locate on site p ) Materials of Co n Dimensions Depth of solids: Comments:(note ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 7 L 2 Sf4f� Owner. �/�/I�f �f'�/re/L Date of Inspeotion: S a^o �• ^� 5 U-3 B h SRETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 64- 3 pG s� I J i MN 0 J ,^1 1 f. f DEPTH TO GROUNDWATER Depth to groundwater. l feet method of determination or approximation: _ 6 d (revised 11/03/95) 9 LOCATION SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME i ADDRESS R'UILDEIt OR OWNER ���carl T�! DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED � � ®��A,� � � �� 0 �/ a �o�' .�y . ., $4 0 .0 0 Fss........................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............ ............TOWN.....OF.......BAIIIIISSABLE:.................----------------................ Appliration for M51111iiFai Works Towitrurtion rantit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: .�...MA...................... Location-Address or Lot No. Cedar Acres...A >�s�.---•....................... 2-4...Gle—At PQ�Id...Dri.--Ve..---S,--XA]�mA�.tb- ...MA Owner , Owner Address aSPero..The..Qbaxldis.................•..-------•----•-----.......... ...........................................S-M....................__...................... Installer Address Type of Building Size Lot...23¢12at.._..Sq. feet Dwelling—No. of Bedrooms.................a.........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building Re Sj_dP_1a_t:,S.].No. of persons.........6................. Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------•••••-••--•-•-•---••---------•••-••••-•-•-•-•-••••.....--•..........••••............•-•----•-- W Design Flow.............5.5....................._. allons per person per day. Total daiil i flow33.0 �lons. WSeptic Tank—Liquid capacit31-0-0-..allons - Length----1Q..6Width Diameter . ....__... Depth(x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.....---.--......... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.....1VQrMA .X... r45 S.maA.......................... Date.AugtAs t,.-3_.___19.0 Test Pit No. 1.......2-......minutes per inch Depth of Test Pit....1.1 4"...... Depth to ground water..NQXI. G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-----..............---. a+ •---•-•-•----•-•••--•••--••••----•-•---••••••-•-.....•••---•••-•---•.......--•-••-•-•-•••----•--••-...........•...............................••......_.•••-- O Description of Soil...S ub soi .......-------•-•-•--------------------•-•-----------•-----------...........-•-•-----------.......--------- x U .................•••••••........_......-•-•--•••••--•••••-•-•--••••••••••-••••---••---••••....•••--•••••••-----•-----•••--•-•--••••--•------•••--•--••-•••••--•-................----•-......-•------•-•-. w UNature of Repairs or Alterations—Answer when applicable................................................................................................ •----------•-----------------------••-----•-----•----------•---•--...-•--------....................-----••-----------------------------------------•---------------------------------....._••-•...-•••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI T= 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has-been issued by th board of health. >gne Application Approved-By.. •• •-• .................................................. ����D = e Date Application Disapproved f th llowing reasons:----•-------•------------------•----•---------•-•------------•----------------=-----------......-----.......•... ...- ......-•-••-•----•••--••....----••...................••-•--•-•••••--••-•-••-........•---------------•--•••-------- ------••••--••-•••••-••--- q� Date Permit No...... �.. ..�l ¢ .................. Issued. f a. 1 �-----�.. . ..... _.� :-tea,.. No..........:` :...: Fu$.....�0 .0 0...._ THE COMMONWEALTH OF MASSACHUSETTS I,* BOARD OF HEALTH ••----...................TOWN....O F.......B.A MS.TABLE. Appliration for Disposal Works Tonstrurtion Frrutit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: _Pinevi ..... D1.Y. f....GS2 �d,1. �... .............._.. . .. ............................................. 4............................................... Location-Address or Lot No. ,Cedar Ficres Realty__ Trust_____ ____ 24 Great Pond__.�ry ,,_,_5..,,_Yarmott,.MA, - ..._... ..... -•.. Owner Address WSpero Theoha_r_ idi_ s................................................ --••-••-••-•---------•••••.......... ...Same...... Installer Address Type of Building Size Lot...243_25:t....Sq. feet Dwelling—No. of Bedrooms.................3.........................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—Type of Building Res..derit...a1No. of persons ................ Showers YP g -•-••-••i ••--- a P ( ) — Cafeteria ( ) dOther fixtures -----------••---------------------•----------......--•••••••-•----•---•-•••••••••-•-•---•-•-•-••-••...•-•----•••--..........--•.............-•..•... W Design Flow..............`�5..........................gallons per person per day. Total daily flow_._......._..330_-•--,____••_- gallons. WSeptic Tank—Liquid capacityl_i.QQgallons Length...10_A. Width.......5...... Diameter................ Depth k 1...... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b Norman Grossman Au ust 3 ____19 8P Y -- -•..................... ..........•-• Date q t Test Pit No. 1.......z......minutes per inch Depth of Test Pit----144....... Depth to ground water.... OIlE?______.... f�4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W " •---•--------•----------------•--•---•--.......-------•-•-------•--•-------•-•-•-••-------------•----•--------......•----•------......•..................... O Subsoil medium sand. Description of Soil ..... -•........ x W M. ................... -•------••-----•-••---•-----•••----•-•---------••••••-•-••--•...••-•-•••-••••-•----•-•••---•-•-••••-••----•-----•-••-••...-----•-••••-••--•--•-••-•••-•---•-•-••-••--•-•-•••..•••--- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ....................••--••.....-•••-•-•--••--••-•-••-•---•-•--•••••-•-••--••-•••-•-••••-•-•-•---•--•-••- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance'has been issued by the board of health. Signed...................................................................................... ................................ Date ApplicationApproved By.................................................................................................. Date Application Disapproved for the following reasons:---•--------•-------•-•-......--•-----------------------------•-----------------•---------------•••-............ .................................. ....................................... .................................................................. •-•---•-•-•- [ d -•............----•-•-- ij .� Permit No.........? �r I................. Issued---j..4i`. ' ------.Date ----- D THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................TOWN.....OF......BARNS TABLE ..... ......... (9rdifirtt#r of Tontpliattrr THIS IS 0 CERTJFY Thai t e Ilvidu 1 wa Dis psal S sse�em c nstruc.ted ( � or Re aired by Spero eoharidib o 4 rea on Drive,, YarmoLi-tli MAp ( ) . . . ............................................... --• --•-••••.........--••••••••...---•-----.................--........................................ Lot 54 Pineview Drive, Cotuit, "Mass sachusetts, ------- ---- ---•-----------•--......_...--•----•---• -------•---..... has been installed in accordance with the provisions of TITLZ 5 of The State Sanitary Code a Nescr•be •n the application for Disposal Works Construction Permit No........ dated....... .__�.... _.. .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE COMTRUED AS A GUAR NTE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 7 DATE............. >.-.......7......�....................................... Inspector......... ............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF.......BARNSTABLE $40 .00 No......................: FEE........................ Disposal Works TOnstrurtion Pgrinit S ero Theoharidis 24 Great Pond Drive S . Yam MA Permission_3s1.hereRbyPngranted..P--------------- � • i to ConstrB61tt( 5�4 oPk&a#i6 ) bjjn vid>eb�16,r �EW' sal System atNo.•-•-••••--•••••••-••-........................---...........-•--•••--•----•--•-•......------•-•.--•-- Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ..........-•---•--•-----•-------•--------------------------------•--------...--••-..........---••......� Board of Health DATE. ---.....--•-••--•-------------•--•-•-••---................•................... FORM; 1255 HOBBS & WARREN. INC., PUBLISHERS _.r AF'111Lr,ICA` '10 �'FJR PERC CLAD ILN �E�i AND OI3SER�t��TIO t P77"S .T 1O SAGE �. r _.__ DATE JCANT FEE S ZSS TELEPHONE NO. (Non-refundable)? NEE TELEPHONE . �® SCHEDULED (Applicant' s signature) o • o 0 0 0 • o • s • • o • o 0 o m o e o a o • • o e e o e e • • • • • • o • • o • • a • e o • • e o e o • • • s • o • • o • e o • • o e • o • o o e s • SOIL LOG •DIVISION NAME p��p/��i�c�a� L'�: DATE TIME :NS ION AREA: YES�NO �/�� �+.�^� ENGINEER: ) f WATER_a.,,PRIVATE WELL "�`��-�, l BOARD OF HEALTH EXCAVATOR 'CH: (Street name,etce ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: ew.-dr4­0 h c-OLATION RATE: T HOLE NO: ELEVATION: TEST HOLE N0: ELEVATION: 1 1 ' 2q`1 2 2 3 3 .• 4 4 _ 5 5 6 6 7 7 8 8 9 ID 9 10 10 ►yyu 12 12 13 13 14 14 % 15 15 16 16 _ TABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS LEACHING TRENCHES SUITABLE FOR SUB-SURFACE SEWAGE. REASONS: 'E : ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICAT ON 'G INAL: COMPLETED IN ENTIRETY BY P. 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