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Home My WebLink About0082 FALLING LEAF LANE - Health 82 Falling Leaf Lane Osterv_ille A 144 —003 - 006 i l' Holmes and Mcgrath, inc LETTER OF TRANSMITTAL civil engineers and land surveyors 205 Worcester Court Unit A4 DATE 11/9/2021 JOBNo. 217101 falmouth, ma. 02540 ATTENTION 508-548-3564 • 800-874-7373 • FAX 508-548-9672 RE: Ms. Janice Davis email:lcoelho@holmesandmcgrath.com #82 Falling Leaf Lane To: DEP Osterville, MA 02655 Attn:Title 5 Program 1 Winter Street,6"'Floor Boston, MA 02108 WE ARE SENDING YOU ®Attached ❑ Under separate cover via the following items: COPIES DATE NO. DESCRIPTION 1 10/14/2021 DEP Approved Inspection and O&M form. I REMARKS: COPY TO: Barnstable Board of Health Janice Davis SIGNED: Luis Coelho LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) A. Installation Important:When Ms. Janice Davis filling out forms Owner on the computer, use only the tab #82 Failing Leaf Lane key to move your Facility Street Address cursor-do not Osterville 02655 use the return City Zip key. Mailing address of owner, if different: rab same Street Address/PO Box: City State Zip (508)428- 1128 ext. Telephone Number B. Authorized Service Provider Holmes and Mcgrath, Inc. 0&M Firm 205 Worcester Court, Unit A4 Street Address Falmouth MA 02540 City State Zip (508) 548 -3564 ext. Telephone Number Luis Coelho 14887 Grade 4M Operator Name Technology Company/Date of Training C. Facility/System Information Gen. Use Cert. #97894 Innovative Ruck Systems Residential RUCK DEP ID Manufacturer ID Model Number 12/2/99 Installation Date Start of Operation Approval Type: ® General ❑ Provisional ❑ Piloting ❑ Remedial Seasonal Residence—used less than 6 mo./year: ❑ Yes ® No D. Operating Information 10/14/21 10/20/20 Inspection Date Previous Inspection Date Blackwater Tank=9" Graywater Tank=7" Pumping Recommended ❑ Yes ® No Sludge Depth(to be checked yearly) t5iaomr.doc• 6-16-06 Page 1 of 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Ellen, Enviro-Septic, RUCK) E. Field Testing — not required for standard inspection of Eljen, Enviro-Septic or RUCK Field Inspection: Color: ® gray ❑ brown ❑ clear ❑ turbid ❑ Other(specify): Odor: ® musty ❑ earthy ❑ moldy ❑ offensive ❑ turbid Effluent Solids: ® no ❑ some pH 6.6 6 to g U DO 2 or greatermg/L Turbidity NTU 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information — not required for standard inspection of Eljen or Eviro-Septic Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gpd Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑ TN ❑ Other(list below) Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection &during this inspection: None Notes and Comments: All components inspected and working properly. The structural integrity of both tanks were good and did not notice any evidence of leakage in or out of the tank. Vents in place and working. The septic tank consisted of only 1" of scum again this year. t5iaomr.doc• 6-16-06 Page 2 of 3 LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Ellen, Enviro-Septic, RUCK) H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted any required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I have attended a trai course for this System with the Technology Company and am listed by the Company a rained inspeWzr. / November 9, 2021 OFF r Siqnattfre Date System owner must submit this report, technology O&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use—by January 31 st of each year for the previous calendar year Piloting Use-within 45 days of inspection date Provisional Use—by March 31th of each year for the previous 12 months General Use—by September 30th of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 6th Floor Boston, MA 02108 t5iaomr.doc• 6-16-06 Page 3 of 3 I Holmes and Mcgrath, inc LETTER OF TRANSMITTAL civil engineers and land surveyors 205 Worcester Court Unit A4 DATE 1/4/2021 JoeNo. 217101 falmouth, ma. 02540 aTrENnoN w 508-548-3564 • 800-874-7373 9 FAX 508-548-9672 !TM email:Icoelho@holmesandmcgrath.com RE: Ms. Janice Davis #82 Falling Leaf Lane t._ rb To: DEP Osterville, MA 02655 Attn:Title 5 Program 1 Winter Street, 6t' Floor `" Boston, MA 02108 WE ARE SENDING YOU ®Attached ❑ Under separate cover via the following items: COPIES DATE NO. DESCRIPTION 1 10/20/2020 DEP Approved Inspection and O&M form. REMARKS: COPY TO: Barnstable Board of Health Janice Davis SIGNED: Luis Coelho LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) A. Installation Important:When Ms. Janice Davis filling out forms Owner on the computer, use only the tab #82 Falling Leaf Lane key to move your Facility Street Address cursor-do not Osterville 02655 use the return City Zip Y rab Mailing address of owner, if different: same Street Address/PO Box: — �w City State Zip (508)428 - 1128 ext. Telephone Number B. Authorized Service Provider Holmes and Mcgrath, Inc. 0&M Firm 205 Worcester Court, Unit A4 Street Address Falmouth MA 02540 City State Zip (508) 548 - 3564 ext. Telephone Number Luis Coelho 14887 Grade 4M Operator Name Technology Company/Date of Training C. Facility/System Information Gen. Use Cert. #97894 Innovative Ruck Systems Residential RUCK DEP ID Manufacturer ID Model Number 12/2/99 Installation Date Start of Operation Approval Type: ® General ❑ Provisional ❑ Piloting ❑ Remedial Seasonal Residence—used less than 6 mo./year: ❑ Yes ® No D. Operating Information 10/20/20 8/28/19 Inspection Date Previous Inspection Date Blackwater Tank=7" Graywater Tank=6" Pumping Recommended ❑ Yes ® No Sludge Depth(to be checked yearly) t5iaomr.doc- 6-16-06 Page 1 of 3 Ji LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) E. Field Testing — not required for standard inspection of EIjen, Enviro-Septic or RUCK Field Inspection: Color: ® gray ❑ brown ❑ clear ❑ turbid ❑ Other(specify): Odor: ® musty ❑ earthy ❑ moldy ❑ offensive ❑ turbid Effluent Solids: ® no ❑ some 6.3 pH 6 to 9 U DO 2 or greater Turbidity NTU 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information — not required for standard inspection of EIjen or Eviro-Septic Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gpd Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑ TN ❑ Other(list below) Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection & during this inspection: None Notes and Comments: All components inspected and working properly. The structural integrity of both tanks were good and did not notice any evidence of leakage in or out of the tank. Vents in place and working. The septic tank consisted of only 1" of scum again this year. t5iaomr.doc• 6-16-06 Page 2 of 3 LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted any required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I have attended a tr *ning course for this System with the Technology Company and am listed by the Compan a traine nspector. January 4, 2021 Op for&6natu Date System owner must submit this report, technology 0&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use— by January 315t of each year for the previous calendar year Piloting Use-within 45 days of inspection date Provisional Use—by March 31th of each year for the previous 12 months General Use—by September 301h of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 6th Floor Boston, MA 02108 t5iaomr.doc• 6-16-06 Page 3 of 3 E Holmes and Mcgrath, inc LETTER OF TRANSMITTAL civil engineers and land surveyors i:.0' 205 Worcester Court Unit A4 DATE 8/30/2019 JOB No. 217101 'ij falmouth, ma. 02540 ATTENTION ;, 508-548-3564 9 800-874-7373 • FAX 508-548-9672 email:Icoelho@holmesandmcgrath.com RE: Ms. Janice Davis #82 Falling Leaf Lane I CD To: DEP Osterville, MA 02655 Attn: Title 5 Program 1 Winter Street,6th Floor Boston, MA 02108 WE ARE SENDING YOU ®Attached ❑ Under separate cover via the following items: COPIES DATE NO. DESCRIPTION 1 8/28/2019 DEP Approved Inspection and O&M form. t F 1 l . REMARKS: COPY TO: :- BarnstableBoard-ofHealth - • - - � - - - - -- -_.. __. ,. _ SIGNED-.. Luis Coelho_ f Massachusetts Department of Environmental Protection ! Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) A. Installation Important:When Ms. Janice Davis filling out forms Owner on the computer, use only the tab #82 Falling Leaf Lane key to move your Facility Street Address cursor-do not Osterville 02655 use the return City Zip key. Mailing address of owner, if different: rab same - -- -- ---- - — — Street Address/PO Box: City State Zip (508) 428 - 1128 ext. _ Telephone Number B. Authorized Service Provider Holmes and Mcgrath, Inc. O&M Firm 205 Worcester Court, Unit A4 _ Street Address ' Falmouth ' MA _ 025401 City - State Zip (508) 548 - 3564 ext. Telephone Number _Luis Coelho_ 14887 Grade 4M _ Operator Name Technology Company/Date of Training C. Facility/System Information- Gen. Use Cert. #97894 Innovative Ruck Sy tems Residential RUCK DEP ID Manufacturer ID Model Number 12/2/99 Installation Date Start of Operation Approval Type: ® General ❑ Provisional ❑ Piloting (I Remedial Seasonal Residence— used less than 6 mo./year: ❑ Yes ® No D. Operating Information 8/28/19 11/15/18 _ Inspection Date Previous Inspection Date Blackwater Tank="' Graywater Tank=5" _ Pumping Recommended ❑ Yes ® No Sludge Depth(to be checked yearly) t5iaomr.doc• 6-16-06 Page 1 of 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 L\ DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) E. Field Testing — not required for standard inspection of Eljen, Enviro-Septic or RUCK Field Inspection: Color: ® gray ❑ brown ❑ clear ❑ turbid ❑ Other(specify): Odor: ® musty ❑ earthy ❑ moldy ❑ offensive ❑ turbid Effluent Solids: ® no ❑ some pH 6.5 6 to 9 U DO 2 or greater Turbidity NTU 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F.. Sampling Information`s not required for standard inspection of Eljen.or Eviro-Septic Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: } } 4 gpd Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑ TN ❑ Other(list below) Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any;maintenance performed since previous inspection &during this inspection: None - -- -- --- Notes and Comments: All components inspected and,workingproperly. The structural integrity of both tanks were good and did not notice any evidence of leakage in or out of the tank. Vents in place and working. The septic tank consisted of only 1/2" of scum again this year. t5iaomr.doc• 6-16-06 Page 2 of 3 i r Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 �\ DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted any required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I have attended a traini g course for this System with the Technology Company and am listed by the Company as rained in ctor. August 30, 2019 0 for Signatur Date . System owner must submit this-report,,-technology O&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use—by January 315t of each year for the previous calendar year Piloting Use -within 45 days of inspection date Provisional Use—by March 31th of each year for the previous 12 months General Use—by September 30th of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 6th Floor Boston, MA 02108 t5iaomr.doc• 6-16-06 Page 3 of 3 c Holmes and Mcgrath, inc LETTER OF TRANSMITTAL civil engineers and land surveyors 205 Worcester Court Unit A4 DATE 12/11/18 JOB No. I 217101 falmouth, ma. 02540 ATTENTION w°+ 508-548-3564 - 800-874-7373 - FAX 508-548-9672 email:Icoelho@holmesandmcgrath.com RE: Ms. Janice Davis #82 Falling Leaf Lane To: DEP Osterville, MA 02655 :y Attn: Title 5 Program + 1 Winter Street, 6'h Floor JI Boston, MA 02108 WE ARE SENDING YOU ®Attached ❑ Under separate cover via the following items: COPIES DATE NO. DESCRIPTION 1 11/15/2018 DEP Approved Inspection and 0&M form. { REMARKS: COPY TO: Barnstable Board of Health Janice Davis SIGNED: Luis Coelho r DEP LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Ellen, Enviro-Septic, RUCK) �5 A. Installation 111 CD Important:When Ms. Janice Davis On filling out forms Owner on the computer, . use only the tab #82 Falling Leaf Lane ,4 key to move your Facility Street Address _ cursor-do not Osterville 02655 use the return key. City Zip t� Mailing address of owner, if different: same Street Address/PO Box: — reRnn City State Zip (508)428- 1128 ext. Telephone Number B. Authorized Service Provider Holmes and Mcgrath, Inc. O&M Firm 205 Worcester Court, Unit A4 Street Address Falmouth MA 02540 City State Zip (508) 548- 3564 ext. Telephone Number Luis Coelho 14887 Grade 4M Operator Name Technology Company/Date of Training C. Facility/System Information Gen. Use Cert. #97894 Innovative Ruck Systems Residential RUCK DEP ID Manufacturer ID Model Number 12/2/99 Installation Date Start of Operation Approval Type: ® General ❑ Provisional ❑ Piloting ❑ Remedial Seasonal Residence—used less than 6 mo./year: ❑ Yes ® No D. Operating Information 11/15/18 10/18/17 Inspection Date Previous Inspection Date Blackwater Tank=4""' Graywater Tank=5" pumping Recommended [I Yes ® No Sludge Depth(to be checked yearly) t5iaomr.doc- 6-16-06 Page 1 of 3 LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Ellen, Enviro-Septic, RUCK) E. Field Testing — not required for standard inspection of EIjen, Enviro-Septic or RUCK Field Inspection: Color: ® gray ❑ brown ❑ clear ❑ turbid ❑ Other(specify): Odor: ® musty ❑ earthy ❑ moldy ❑ offensive ❑ turbid Effluent Solids: ® no ❑ some pH 6 to 9 SU DO 2 or greatermg/L T NTU Turbidity 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information — not required for standard inspection of Eljen or Eviro-Septic Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gpd Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑ TN ❑ Other(list below) Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection &during this inspection: None Notes and Comments: All components inspected and working properly. The structural integrity of both tanks were good and did not notice any evidence of leakage in or out of the tank. Vents in place and working. The septic tank consisted of only 1/2" of scum again this year. t5iaomr.doc• 6-16-06 Page 2 of 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Ellen, Enviro-Septic, RUCK) H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted any required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I have attended a training course for this System with the Technology Company and am listed by the Company as;atr7�,e"`d inspector. December 11, 2018 Ope for ature Date System owner must submit this report, technology 0&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use—by January 31 st of each year for the previous calendar year Piloting Use -within 45 days of inspection date Provisional Use—by March 31th of each year for the previous 12 months General Use—by September 30th of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program, One Winter Street, 6th Floor Boston, MA 02108 t5iaomr.doc- 6-16-06 Page 3 of 3 1 Innovative Ruck Systems, inc LETTER OF TRANSMITTAL civil engineers and land surveyors 205 Worcester Court Unit A4 DATE 11/7/17 JOBNO. 217101 tw falmouth, ma. 02540 ATTENTION 508-548-3564 - 800-874-7373 - FAX 508-548-9672 email:Icoelho@holmesandmcgrath.com RE: Ms.Janice Davis h+a x #82 Falling Leaf Lane fwt To: DEP Osterville, MA 02655 Attn:Title 5 Program i 1 Winter Street, 6th Floor " =y Boston, MA 02108 WE ARE SENDING YOU ®Attached ❑ Under separate cover via the following items: COPIES DATE NO. DESCRIPTION 1 10/18/2017 DEP Approved Inspection and 0&M form. REMARKS: COPY TO: Barnstable Board of Health Janice Davis SIGNED: Luis Coelho I Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) A. Installation Important:When Ms. Janice Davis filling out forms Owner on the computer, use only the tab #82 Falling Leaf Lane key to move your Facility Street Address cursor-do not Qsteryllle use the return 02655 _ key. City Zip Mailing address of owner, if different: same Street Address/PO Box: remm City State Zip (508) 428- 1128 ext. Telephone Number B. Authorized Service Provider Innovative Ruck Systems, Inc. 0&M Firm 205 Worcester Court, Unit A4 Street Address Falmouth MA 02540 City State Zip (508) 548-3564 ext. Telephone Number Luis Coelho 14887 Grade 4M Operator Name Technology Company/Date of Training C. Facility/System Information Gen. Use Cert. #97894 Innovative Ruck Systems Residential RUCK DEP ID Manufacturer ID Model Number 12/2/99 Installation Date Start of Operation Approval Type: ® General [:].Provisional ❑ Piloting ❑ Remedial Seasonal Residence—used less than 6 mo./year: ❑ Yes ® No D. Operating Information 10/18/17 10/25/16 Inspection Date Previous Inspection Date Blackwater Tank=8"' Graywater Tank=4" Sludge Depth(to be checked yearly) Pumping Recommended ❑ Yes ® No t5iaomr.doc• 6-16-06 Page 1 of 3 Massachusetts Department of Environmental Protection LI\: Bureau of Resource Protection - Title 5 DEP Approved Ins Inspection and OW Form for Title 5 I/A Treatment and Disposal Systems (Ellen, Enviro-Septic, RUCK) E. Field Testing — not required for standard inspection of Eljen, Enviro-Septic or RUCK Field Inspection: Color: ❑ gray ❑ brown ® clear ❑ turbid ❑ Other(specify): — Odor: ® musty El earthy El moldy El offensive ❑ turbid Effluent Solids: ® no ❑ some 6.7 SU 1.86 mg/L NTU pH 6 to 9 DO 2 or greater Turbidity 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information — not required for standard inspection of Eljen or Eviro-Septic Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gpd Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑ TN ❑ Other(list below) Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection &during this inspection: None Notes and Comments: All components inspected and working properly. The structural integrity of both tanks were good and did not notice any evidence of leakage in or out of the tank. Vents in place and working. The septic tank consisted of only 112"of scum again this year. i t5iaomr.doc- 6-16-06 Page 2 of 3 1 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Ellen, Enviro-Septic, RUCK) H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted any required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I have attended a train g course for this System with the Technology Company and am listed by the Company trained insi Vor. ��' November 7, 2017 0 or Signature Date System owner must submit this report, technology 0&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use— by January 315t of each year for the previous calendar year Piloting Use-within 45 days of inspection date Provisional Use—by March 31th of each year for the previous 12 months General Use—by September 301h of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 6th Floor Boston, MA 02108 t5iaomr.doc• 6-16-06 Page 3 of 3 Innovative Ruck Systems, inc LETTER OF TRANSMITTAL civil engineers and land surveyors 205 Worcester Court Unit A4 DATE 11/21/16 JOB NO. 214055 falmouth, ma. 02540 508-548-3564 - 800-874-7373 - FAX 508-548-9672 ATTENTION email:Icoelho@holmesandmcgrath.com RE: Ms.Janice Davis #82 Falling Leaf Lane To: DEP Osterville, MA 02655 Attn:Title 5 Program 1 Winter Street, 6th Floor Boston, MA 02108 WE ARE SENDING YOU ®Attached ❑ Under separate cover via the following items: COPIES DATE NO. DESCRIPTION 2 10/25/2016 DEP Approved Inspection and O&M form. REMARKS: COPY TO: Barnstable Board of Health Janice Davis SIGNED: Luis Coelho Massachusetts Department of Environmental Protection Ll Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) A. Installation Important:When Ms. Janice Davis filling out forms Omer on the computer, use only the tab #82 Falling Leaf Lane key to move your Facility Street Address cursor-do not Osterville use the return 02655 key. City Zip Mailing address of owner, if different: same Street Address/PO Box: reaan City State Zip (508)428 - 1128 ext. Telephone Number B. Authorized Service Provider Innovative Ruck Systems, Inc. O&M Firm 205 Worcester Court, Unit A4 Street Address Falmouth MA 02540 City State Zip (508) 548-3564 ext. Telephone Number Luis Coelho 14887 Grade 4M Operator Name Technology Company/Date of Training C. Facility/System Information Gen. Use Cert. #97894 Innovative Ruck Systems Residential RUCK DEP ID Manufacturer ID Model Number 12/2/99 Installation Date Start of Operation Approval Type: ® General ❑ Provisional ❑ Piloting El Remedial Seasonal Residence—used less than 6 mo./year: ❑ Yes ® No D. Operating Information 10/25/16 10/28/15 Inspection Date Previous Inspection Date Blackwater Tank=6" Graywater Tank=4" Sludge Depth(to be checked yearly) Pumping Recommended ❑ Yes ® No M t5iaomr.doc- 6-16-06 Page 1 of 3 I �— Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) E. Field Testing — not required for standard inspection of Eljen, Enviro-Septic or RUCK Field Inspection: Color: ❑ gray ❑ brown ® clear ❑ turbid ❑ Other(specify): Odor: ® musty ❑ earthy ❑ moldy El offensive ❑ turbid Effluent Solids: ® no ❑ some pH 6.5 SU DO 2.6 mg/L NTU 6 to 9 2 or greater Turbidity 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information — not required for standard inspection of Eljen or Eviro-Septic Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gpd Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑TN ❑ Other(list below) Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection & during this inspection: None Notes and Comments: All components inspected and working properly. The structural integrity of both tanks were good and did not notice any evidence of leakage in or out of the tank. Vents in place and working. The septic tank consisted of only 1/2"of scum. M t5iaomr.doc• 6-16-06 Page 2 of 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted any required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I have attended a trai 'ng course for this System with the Technology Company and am listed by the Company rained ins ctor. November 21, 2016 0 for ignature Date System owner must submit this report, technology O&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use— by January 315t of each year for the previous calendar year Piloting Use-within 45 days of inspection date Provisional Use—by March 311h of each year for the previous 12 months General Use—by September 301h of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 6th Floor Boston, MA 02108 t5iaomr.doc• 6-16-06 Page 3 of 3 Innovative Ruck Systems, inc LETTER OF TRANSMITTAL civil engineers and land surveyors 205 Worcester Court Unit A4 DATE 11/11/15 JDBND. 214055 falmouth, ma. 02540 ArrENnoN 508-548-3564 • 800-874-7373 • FAX 508-548-9672 email:Icoelho@holmesandmcgrath.com RE: Ms.Janice Davis #82 Falling Leaf Lane To: DEP Osterville, MA 02655 Attn:Title 5 Program 1 Winter Street,6'h Floor Boston, MA 02108 WE ARE SENDING YOU ®Attached ❑ Under separate cover via the following items: COPIES DATE NO. DESCRIPTION 2 10/28/2015 DEP Approved Inspection and 0&M form. REMARKS: a COPY TO: Barnstable Board of Health Janice Davis SIGNED: Luis Coelho LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-septic, RUCK) A. Installation Important:When Ms. Janice Davis filling out forms Owner on the computer, use only the tab #82 Falling Leaf Lane key to move your Facility Street Address cursor-do not Osterville 02655 use the return City Zip key. Mailing address of owner, if different: tab same Street Address/PO Box: rtmxn City State Zip (508) 428 - 1128 ext. Telephone Number B. Authorized Service Provider Innovative Ruck Systems, Inc. O&M Firm 205 Worcester Court, Unit A4 Street Address Falmouth MA 02540 City State Zip (508) 548- 3564 ext. Telephone Number Luis Coelho 14887 Grade 4M Operator Name Technology Company/Date of Training C. Facility/System Information Gen. Use Cert. #97894 Innovative Ruck Systems Residential RUCK DEP ID Manufacturer ID Model Number 12/2/99 Installation Date Start of Operation Approval Type: ® General ❑ Provisional ❑ Piloting ❑ Remedial Seasonal Residence—used less than 6 mo./year: ❑ Yes ® No D. Operating Information 10/28/15 11/11/14 Inspection Date Previous Inspection Date Blackwater Tank=8" Graywater Tank=3" Sludge Depth(to be checked yearly) Pumping Recommended ❑ Yes ® No t5iaomr.doc 616-06 Page 1 of 3 !j LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-septic, RUCK) E. Field Testing — not required for standard inspection of Elien, Enviro-Septic or RUCK Field Inspection: Color: ❑ gray ❑ brown M clear ❑ turbid ❑ Other(specify): Odor: ® musty ❑ earthy ❑ moldy ❑ offensive ❑ turbid Effluent Solids: ® no ❑ some pH 6.4 SU DO 3.0 mg/L Turbidity NTU 6 to 9 2 or greater 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information — not required for standard inspection of Eljen or Eviro-Septic Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gpd Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑TN ❑ Other(list below) I Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection &during this inspection: None Notes and Comments: All components inspected and working properly. The structural integrity of both tanks were good and did not notice any evidence of leakage in or out of the tank. Vents in place and working. The septic tank consisted of only 1/2" of scum. t5iaomr.doc• 6-16-06 Page 2 of 3 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Ll Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted any required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I have attended a train' g course for this System with the Technology Company and am listed by the Company as rained ins ctor. 11/11/2015 Ope ator Signature Date System owner must submit this report, technology O&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use—by January 31st of each year for the previous calendar year Piloting Use -within 45 days of inspection date Provisional Use—by March 31 th of each year for the previous 12 months General Use—by September 301h of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 61h Floor Boston, MA 02108 t5iaomr.doc• 6-16-06 Page 3 of 3 I rf . Innovative Ruck Systems, inc LETTER OF TRANSMITTAL civil engineers and land surveyors 205 Worcester Court Unit A4 DATE 11/18/14 JOBNo. 209002 falmouth, ma. 02540 ATTENTION 508-548-3564 • 8010-874-7373 • FAX 508-548-9672 email:Icoelho@holmesandmcgrath.com RE: Ms.Janice Davis #82 Falling Leaf.Lane To: DEP Osterville, MA 02655 Attn:Title 5 Program 1 Winter Street,6t'Floor Boston, MA 02108 WE ARE SENDING YOU ®Attached ❑ Under separate cover via the following items: COPIES DATE NO. DESCRIPTION 2 11/11/ 0014 DEP Approved Inspection and O&M form. REMARKS: COPY TO: /Barnstable Board of Health`"`=�, Janice Davis SIGNED: Luis Coelho LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eijen, Enviro-Septic, RUCK) A. Installation Important:When Ms. Janice Davis filling out forms Owner on the computer, use only the tab #82 Falling Leaf Lane key to move your Facility Street Address cursor-do not Osterville 02655 use the return key. City Zip Mailing address of owner, if different: same Street Address/PO Box: City State Zip (508)428- 1128 ext. Telephone Number B. Authorized Service Provider Innovative Ruck Systems, Inc. O&M Firm 205 Worcester Court, Unit A4 Street Address .Falmouth MA 02540 City State Zip (508)548-3564 ext. Telephone Number Luis Coelho 14887 Grade 4M Operator Name Technology Company/Date of Training C. Facility/System Information Gen. Use Cert. #97894 Innovative Ruck Systems Residential RUCK DEP ID Manufacturer ID Model Number 12/2/99 Installation Date Start of Operation Approval Type: ® General ❑ Provisional ❑ Piloting ❑ Remedial Seasonal Residence—used less than 6 mo./year: ❑ Yes ® No D. Operating Information 11/11/14 9/26/13 - Inspection Date Previous Inspection Date Blackwater Tank=9" Graywater Tank=6" Pumping Recommended Sludge Depth(to be checked yearly) P 9 Yes No t5iaomr.doc- 6-16-06 Page 1 of 3 1 LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) E. Field Testing - not required for standard inspection of Eljen, Enviro-Septic or RUCK Field Inspection: Color: El gray ❑ brown ® clear El turbid ❑ Other(specify): Odor: ® musty ❑ earthy ❑ moldy ❑ offensive ❑ turbid Effluent Solids: ® no ❑ some pH 6.0 SU DO 1.86 mg/L Turbidity NTU 6 to 9 2 or greater s 40 or less . Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information — not required for standard inspection of Eljen or Eviro-Septic Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gpd Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑TN ❑ Other(list below) Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection &during this inspection: None Notes and Comments: All components inspected and working properly. The structural integrity of both tanks were good and did not notice any evidence of leakage in or out of the tank. Vents in place and working. The septic tank consisted of only 1/2"of scum. t5iaomr.doc• 6-16-06 Page 2 of 3 LIMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP .Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eiien, Enviro-Septic, RUCK) H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted any required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I have attended a train' course forth' System with the Technology Company and am listed by the Compan as rained ins. r. 11/18/14 O or Signature Date System owner must submit this report, technology O&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use-by January 31st of each year for the previous calendar year Piloting Use-within 45 days of inspection date Provisional Use—by March 31th of each year for the previous 12 months General Use by September 30th of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 6th Floor Boston,'MA 02108 t5iaomr.doc• 6-16-06 Page 3 of 3 ,F rr � holmes and mcgrath, inc. LETTER OF TRANSMITTAL civil engineers and land surveyors 205 Worcester Court Unit A4 DATE 10/24/12 JOBNO. 209002 falmouth, ma. 02.540 ATTEw6N 508-548-3564 • 800-874-7373 9 FAX 508-548-9672 email:mcgrath@holmesandmcgrath.com RE: Ms.Janice Davis 482 Falling Leaf Lane J To: DEP Osterville, MA 02655 Attn:Title 5 Program 1 Winter Street,6 Floor Boston, MA 02108 WE ARE SENDINGYOU ®Attached ❑ Under separate cover via the following items: COPIES DATE NO. DESCRIPTION 1 10/16/2012 DEP Approved Inspection and O&M form. V REMARKS: ZEE M^a COPY TO: ( Barnstable Board of Health "Janice Davis- --- ` SIGNED: Luis Coelho i LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and ,O&M Form for Title 5 I/A Treatment and Disposal SyStems (Eljen, Enviro-Septic, RUCK) A. Installation Important: Ms. Janice Davis When filling out Owner forms on the computer;use #82 Falling Leaf Lane only the tab key Facility Street Address to move your Osterville 02655 cursor-do not use the return City zip key. Mailing address of owner, if different` same Street Address"/PO Box: City State Zip (508)428- 1128 ext. Telephone Number B. Authorized Service Provider Innovative Ruck Systems, Inc. O&M Firm 362 Gifford Street Street Address Falmouth MA 02540 City State Zip (508) 548-.3564 ext. Telephone Number' Luis Coelho 14887.Grade 4M Operator Name Technology Company/Date of Training C. Facility/System Information Gen: Use Cert.#97894 Innovative Ruck Systems Residential.RUCK DEP ID ManufacturerID Model Number 12/2/99 Installation Date Start of Operation Approval Type' ® General ❑ Provisional ❑ Piloting ❑ Remedial Seasonal Residence=used less than 6 mo./year: ❑ Yes No D. Operating Information 10/16/12 10/21/11 Inspection'Date Previous Inspection Date Blackwater Tank=4" Graywater Tank=6" Pumping Recommended ❑ Yes ® No Sludge Depth(to be checked yearly) t5iaomr.doc• 6-16-06 Page 1 of 3 LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (EUen., En,viro-Septic, RUCK) E. Field Testing — not required for standard inspection of Elje_n, Enviro=Se tic or RUCK Field Inspection: Color: ❑ gray ❑ brown ® clear ❑ turbid ❑ Other(specify): Odor: ® musty ❑ earthy ❑ moldy ❑ offensive ❑ turbid Effluent Solids: H no ❑ some NTU pH 6 to 9 SU DO 2 or 9 rea erg/L Turbidity 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed forBOD and TSS. F. $allnpling InfOrmatlOn - not required for standard inspection of Eljen or Evko-Septic Samples.Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gPd Parameters sampled: ❑ pH ❑ BOD'❑ CBOD ❑ TSS ❑TN ❑ Other(list below) Other 1 Other 2 Other 1 . G. Inspection and Maintenance Description of any maintenance performed since previous inspection &during-this inspection: . None Notes and Comments: All components inspected and working properly. The structural integrity of both tanks were good.and did not notice any evidence'of leakage in or out of the tank.Vents in place and working. The septic tank consisted of.only'V/ " of scum again this year at time of inspection. t5iaomr.doc• 6-16-06 Page 2 of 3 �r Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) H. Certification I certify: I have inspected'the sewage treatment and disposal system at the address above, have conducted.any required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist,and the information reported is true., accurate, and complete as of the time of the inspection. I have attended a tr 'ning cour5lefor this System with the Technology Company and am listed by the Compan Y s a traine ' specter: 10/24/12 ekle'riftor Sign re Date System owner must submit this report, technology OW checklist, and any required sampling results to'the local board of health and DEP as follows for each inspection performed: Remedial Use-by January 31st,of each year for the previous calendar year Piloting Use-within 45 days of inspection date Provisional Use-by-March. 3.1`h of each year for the previous 12 months . General Use by September 30'h of each year for the previous 12 months Send to: .Department of Environmental Protection Attention: Title 5 Program One Winter Street, 6th Floor Boston, MA 02108 i t5iaomr.doc• 6-16-06 Page 3 of 3 I� i�r_ — 003 _ ooG holmes and mcgrath, inc. LETTER OF TRANSMITTAL civil engineers and land surveyors 362 gifford street DATE 10/27/10 JOB No. 209002 I falmouth, ma. 02540 ATTENTION 508-548-3564 • 800-874-7373 • FAX 508-548-9672 email:mcgrath@holmesandmcgrath.com RE: Ms. Janice Davis #82 Falling Leaf Lane To: DEP Osterville, MA 02655 Attn:Title 5 Program 1 Winter Street,6 Floor Boston, MA 02108 WE ARE SENDING YOU ®Attached ❑ Under separate cover via the following items: COPIES DATE NO. DESCRIPTION 1 1OM2010 DEP Approved Inspection and O&M form. REMARKS: CQPY_T-O: Barnstable Board of Health Janice Davis' y SIGNED: Luis Coelho T-�WN,OF BARNSTABLE LOCATION I;a �Or\�: �e z t., SEWAGE # 9 " J"`I VILLAGE O5kvovN ASSESSOR'S MAP & LOT 44 a INSTALLER'S NAME&PHONE NO. C=,,, . Li 21- BSOp SEPTIC TANK CAPACITY "A a,;.LEACHING FACILITY: ` X Ze NO.OF BEDROOMS BUILDER OR OWNER WNcS�Ma.4 ca'%X-. CJ PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching.Facility Feet Private Water.,Supply Well and Leaching Facility (If any wells exist on site of within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist withIin300 feet of leaching facility) Feet Furnished by azr,lf�i A3d Zo a5�3q 'w4 BY � a �ry 7 , - - TOWN OF BATSTABLE Pool' LOCATION Lb SEWAGE # ' VILLAGE CSypll ASSESSOR'S MAP & LOT4 603 0 17 INSTALLER'S NAME&PHONE NO. 2 `SAS C4 SEPTIC TANK CAPACITY bO { [a O® f i LEACHING FACILITY: (type) ±1 1. i (size). NO. OF BEDROOMS_ BUILDER OR OWNERL �_ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r u2' 3718 ST S aS`t-1' rl Z 167 - 30' t 7= � cf Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) A. Installation Important: Ms. Janice Davis When filling out Owner forms on the computer, use #82 Falling Leaf Lane only the tab key Facility Street Address to move your Osterville cursor-do not 02655 use the return city Zip key. Mailing address of owner, if different: VQ same Street Address/PO Box: city State Zip (508)428- 1128 ext. Telephone Number B. Authorized Service Provider v o Innovative Ruck Systems, Inc. o O&M Firm 362 Gifford Street o p Street Address tV Falmouth MA 02540 %o City State Zip 'E!—�� (508) 548 -3564 ext. Telephone Number W Luis Coelho CD rn 14887 Grade 4M Operator Name Technology Company/Date of Training C. Facility/System Information Gen. Use Cert. #97894 Innovative Ruck Systems Residential RUCK DEP ID Manufacturer ID Model Number 12/2/99 Installation Date Start of Operation Approval Type: ® General ❑ Provisional ❑ Piloting ❑ Remedial Seasonal Residence—used less than 6 mo./year: ❑ Yes ® No D. Operating Information 10/7/10 9/23/09 Inspection Date Previous Inspection Date Blackwater Tank=9" Graywater Tank=8" Sludge Depth(to be checked yearly) Pumping Recommended ❑ Yes ® No t5iaomr.doc- 6-16-06 Page 1 of 3 y Massachusetts Department of Environmental Protection LLI Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Eljen, Enviro-Septic, RUCK) E. Field Testing — not required for standard inspection of Eljen, Enviro-Septic or RUCK Field Inspection: Color: ❑ gray ❑ brown clear ❑ turbid ❑ Other(specify): Odor: ® musty El earthy El moldy ❑ offensive El turbid Effluent Solids: ® no ❑ some pH SU DO mg/L NTU 6 to 9 2 or greater Turbidity 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information — not required for standard inspection of Eljen or Eviro-Septic Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: gpd Parameters sampled: ❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑ TN ❑ Other(list below) Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection & during this inspection: None Notes and Comments: All components inspected and working properly. The structural integrity of both tanks were good and did not notice any evidence of leakage in or out of the tank Vents in place and working. t5iaomr.doc• 6-16-06 Page 2 of 3 l LLIMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems (Ellen, Enviro-Septic, RUCK) H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted any required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I have attended raining co a for this System with the Technology Company and am listed by the Comp as a trai tor. 10/27/10 e for Signat Date System owner must submit this report, technology O&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use—by January 31st of each year for the previous calendar year Piloting Use-within 45 days of inspection date Provisional Use—by March 31th of each year for the previous 12 months General Use—by September 30th of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 6t Floor Boston, MA 02108 t5iaomr.doc• 6-16-06 Page 3 of 3