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1304 Main Street Osterville5 A= 119-1.'079 i t r*- 09/3012010 20:32 6022780608 ONYXL�t PAGE 02 491981 (D VEOLIA D614919 ENVIRONMENTAL SERVICE TECHNICAL SOLUTIONS NORTH AMEItICA Customer, Generator: WC,M LIGHTSHIP DENTAL 6054 CORTE DEL CEDRO 1322 MAIN STREET CARLSBAD,CA 92011-1514 OSTERVILLE,MA 02655 Veolia ES Technical Solutions L.L.C. A70000337360 Certificate of Recycling and/or Disposal ManifestBOL Number WCM491981-7 F Duanti4l Unit of Meaaure 4orial ether - Recycle-Dental Amalgam,unu5cd 4 P N/A By accepting the waste products described on the shipping paper referenced above, Veolia ES Technical Solutions, . L.L.C. certifies to the generator that the transportation,storage, and processing methods employed are in accordance with Veolia ES permit parameters, the Toxic Substance Control Act, the Resource Conservation and Recovery.Act, the Hazardous Materials Transportation Act, the Occupational Health and Safely Act and all applicable federal, state and local laws. Under civil and criminal penalties of law for the making or submission offalse or fraudulent statements or representations(18 U.S.C. 1001 and 15 U.S.0 26f 5),1 certify that the information contained in or accompanying this document is hue, accurate, and complete, As to the identified section(s)of this documentfor which I cannot personally verify truth and accuracy,I certify as the company official having supervisory responsibility for the persons who, acting under my direct instructions, made the verification that this information is true, accurate, and complete. (t Operations.Manager Date Received: 6110./201.0 Vooki ES TeOnigml Solution$,LLC. 593e w leeffer!,on Street,Phoenix,AZ 35043 tel;6o2 z33 z955-toll free;goo 368 9095-fax;602 415 3030 www,VcoliaES.com r Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIF@ST { $ v#? , ? -? 0 FLE S.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) UF AIM t-All - Il�ibf4� rd Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number MAR-XAKK fF�� 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number inn r,.:tdtq��k��afno`Ste=r� sa�'��311'a. Q[ts Facility's Phone A" �62 IASI ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt./Vol. 114.fi7' ft kxrlrc i f�rf ( rd(s6i( f} I `s NA13 ,a01 l O 4.^:.-�'x{� �'� ail•�xed<..::t'a3E9ag�i.rs rr.:7,t t4d9.,L..i,b'a a t.,r 111 2 2. 1f Ord.:+��.;i xY"E�l�sai:gs.ig'�"v1� tr..m''.it`•e�N+.x�i4s€:� f~a�4d�15,ht:, i�`sF+.::r'�(`� � fA� ,w'� 3. "l 4 14.Special Handling Instructions and Additional Information 1#44 a wAoi•4wofflort 0 eft moid?# t ';se1 oe Ill%uq&e w Iftaaf.ara xacom W*oo(1404 4;0WA fit 114walir t. oft Sao w t i w a A I gl r�i taa Via:re2ksf> d&�n: aaayd y�tsf#aa$1 3ftsaaa$fe#a rflt rt f tftaf oil r�fsrftnsf��rlrt f �tf�� M04A P4 ifsfh'a,.� fra{;��! "f= ft. ry 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, t marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator'si0fferor's PrinledfTyped Name gna ure on ay Year —i 16.International Shipments F— 0 Import to U.S. El Export from U.S. Port of entrylexit: Transporter signature for exports on Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials U Transporter 1 Printed/Typed Name Signature t' onth ay year a Transporter 2 Printed/Typed Name Signature Month Day Year f- 18.Discrepancy 18.a.Discrepancy Indication Space El Quantity ❑ ❑Residue Partial Rejection Type ❑Full Re ❑ jection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number a , r u- Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(Le„codes for hazardous waste treatment,disposal,and recycling systems) p 1, ~ .�' Rk 2. T . 4. Fnt nated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a ypec Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY Dental Amalgam Mercury Recycling MassDEP, Page 1 of 6 t . Skip Navigation MassDEP Home Mass,Gov Home State Agencies State Online Services site.map contacts search: dep home>service center 99, . ---. MassDEP Quick Links: m-,., _ _ IP_ About MassDER Public Participation &NIeVds. Dental°amalgam/Mercury Recycling Air s Climate Introduction 1 _ Regulations& Program Requirements Water,Wastewater s:4lVetlands Compliance Certification Forms&Deadlines Wastes:Pecycliing Amalgam Separators - - ------ Managing &'Recycling Amalgam &'Mercury Wastes Toxics&H;azardis 'Record-Keeping Requirements For More Information Cleanup of Sites& spills Service Cetatel, Service Center:Dental Amalgam/Mercury Recycling laws and rules Introduction. permits, reporting&forms :.::.:........ ...... ..:: ..... online services Amalgam waste from dental practices and clinics is a significant source of m compliance assistance to the environment when it is thrown into the trash or washed down,a drain. j environmental results program Massachusetts study of several commercially available amalgam separator t&kn.ei'e�rs.d confirmed that they effectively remove most mercury from dental wastewater enforcement&appeals ! grants&financial assistance The Massachusetts Department of Environmental Protection (MassDEP) is v training&professional reductions of mercury releases to the environment from dental practices and certification ; phases: r . � Calendar First,the agency implemented a voluntary program with the.Massach Society(MDS)to encourage early installation and use of amalgam se My Community dentists. Online Services' . 'Second,M'bssDEP •issued regulations that require most dental practic 7 fin Massachusetts to install and operate amalgam separator systems, 1 Regional Offices °mercury-containing amalgam wastes,and periodically certify their comP��u�-�-e- on Report P Ik ithese requirements. ,�j tttt �t - �kA The regulations,which took effect on April 24, 2006, were developed with as stakeholder workgroup including individual dentists, MDS representatives, st tQ 1(, authorities, and environmental groups. �) Back to Dental Amalgam/Mercury Recycling index ht,tp://www.mass.gov/dep/service/dentists.htm 9/21/2010 Dental Amalgam Mercury Recycling MassDEP Page 2 of 6 Service Center:Dental Amalgam/Mercury Recycling Regulations & Program Requirements ............ ..........o.................... ........................................ ................................................... 310 CIVIR 73.00: Amalgam Wastwater& Recycling Regulations for Dental F� Web page Note-These regulations apply to all derital practices and facilities located in Massz that-do not generate or discharge wastewater from amalgam-related processes(i.e limited to oral and maxillofacial,orthodontic,periodontic,and/or oral medicine prac ,mercury-free-filling material,or do not place or remove mercury amalgam are not r amalgam separators, but need to file one-time certifications to establish their exerr The Dental Amalgam/Mercury Recycling certification program requires dentz facilities to certify to MassDEP.every five years that they: • Have installed an amalgam separator system that,serves every denta practice or facility.where waste amalgam is generated. The system m 'has been demonstrated to remove at least 98 percent of the amalgan containing mercury(using the ISO 11 143,protocol or an equivalent m, acceptable to MassDEP). • Maintain and operate the amalgam separator system according to,me specifications. e Ose only non-corrosive and bio'degradable cleaners to clean ean vacuum Recycle all amalgam waste,containing mercury. Ensure that facility,staff are informed about procedures for handling \A and that at least one employee is familiar with procedures for operatir, maintaining the installed,amalgam separatorr system. Keep records to document that the,program. requirements are being n. A Note About Amalgam Separators Installed by Voluntary-Program Participa While the voluntary program required t,hat,amalgam separators be demonstrated t( percent efficiency in removing waste amalgam from wastewater,the.reg6lations re amalgam separators meet a 98 percent removal efficiency standard. Facilities that voluntary program are allowed to continue using their 95 percent efficient arnalgan long as the equipment continues to achieve this.removal efficiency and is maintain with manufacturer instructions.When separators need to be replaced,units that m removal efficiency standard must be installed. Back to Dental Amalgam/Mercury Recycling index Service Center:Dental Amalgam/Mercury R.ecyciing Compliance Certification Forms & Deadlines, .................... .......... ..............I................. ............. Compliance Certification Forms: File Online or by Mail Web page http'://www.mass.gov/dep/service/dentists.htm 9/21/2010 Dental Amalgam Mercury Recycling J,MassDEP,l Page 3 of 6 Deadline for Certification Fllin 9 • Massachusetts dental practices that did not participate in the voluntar install and use amalgam separators, recycle amalgam waste containi and file their initial certifications by June 22, 2006. • Dental practices and facilities.that are exempt from the regulation mu: certifications to establish their exempt status by June 22, 2006. • New dental practices and those that expand beyond the capacity of tl • amalgam separator(s)must install new amalgam separator equipmer new facilities start.operating, and must file initial certifications with Ma 60'days of startup.. o Dental facilities that joined the voluntary program during its first year January 31, 2004, and February 28,2005) must file their first requirec by June 15, 2010. • Dental facilities that joined the voluntary program during its second YE March 1, 2005, and April 21, 2006) must file their first required certific 15, 2007. • After initial certifications are filed with MassDE'P, follow-up certificatiol every five years (by June 15 of the year they are due): Back to'Dental Amalgam/Mercury,Recycling index' service Center:Dental Amalgam/Mercury Recycling' Amalgam Separators List of.Amalgam Separator.Technologies Approved for Use in Massachusett Web page Amalgam separators remove.particles of amalgam from wastewater that pas your facility's vacuum system,vacuum line filters and screens, and/or chair before the wastewater is discharged to a sewer. • 'Amalgam separators must be demonstrated to remove at least 98 pel waste amalgam in wastewater.These demonstrations are usually cor professional laboratories at the request of the separator manufactures specific protocol developed�by the.lnternational Organization for Stan (ISO protocol 11143). . • ,Facilities that participated in the voluntary program are allowed to cor their95 percent efficient amalgam separators,as.long as the equipm( achieve this removal efficiency and is maintained in accordance with instructions. When separators need to be replaced, units that meet th removal efficiency standard must be installed. • The separator must serve all wastewater that contains waste amalgal wastewater from chairs and cuspidors), and needs to be sized to accc facility's maximum amalgam wastewater flow. http://www.mass.gov/dep/service/dentists.htm 9/21/2010 Dental Amalgam Mercury Recycling] MassDEP Page 4 of 6 • The separator must be installed, operated, and maintained according manufacturer's instructions. - • At Least one.employee must be familiar with theprocedures for opera maintaining your amalgam separator system. In addition; all staff handle waste amalgam must be informed about these procedures. Cleaning & Disinfecting Vacuum Lines& Drains .. Use only disinfectants and cleaning agents that are biodegradable,nt (pH f between 6;5.and 9.0)and non-oxidizing in your facility's vacuum I other drains that are connected to amalgam separator equipment: • Bleach is not an acceptable disinfectant, since it mobilizes the mercur separatorand prevents the.separator from capturing waste amalgam. Follow manufacturer instructions on appropriate disinfectants, cleanin maintenance procedures. Back to.Dental Amalgam/Mercury Recycling index Service Center:Dental Amalgam/Mercury Recycling Managing & Recycling'Amalgam &.Mercury Wastes List of Companies That Provide Amalgam Mercury Recycling Services `Web page Recommended Practices for Handling Amalgam & Mercury Wastes Web page All amalgam waste generated at dental practices and facilities must be sent reclaim mercury from the amalgam waste material. This is-a'form ofrecyclinc throw amalgam waste into the trash (i.e., to treat it as'solid,waste)or to mix medical or"red bag"waste.. There are two types of amalgam wastes:, • Contact amalgam has been used on patients and generally includes E scrap amalgam from removed fillings, chair-side traps and screens a' vacuum pump filters, amalgam separators, and other devices that ca[ amalgam. • Non-contact amalgam has never been used on patients and generally broken and unusable amalgam capsules, excess amalgam, and empi from restorative treatments. All amalgam wastes should be stored safely in air-tight containers with secur enough has been collected for shipment to a reclamation facility or recycler. recommended practices for handling amalgam wastes. http://www.mass.gov/dep/service/dentists.htm 9/21/2010 Dental Amalgam Mercury Recycling MassDEP Page 5 of 6 To recycle amalgam waste, you may send it directly to a recycling facility tha a Class A Hazardous Waste Recycling Permit from MassDEP, or a recycling in another state that is authorized by that state to reclaim mercury. You may licensed hazardous waste facility or a consolidation facility, which will in turn amalgam waste to a reclamation facility. A common carrier(such,as the U.S. Postal Service, United Parcel Service, F Express, or other shipping service) may be used to transport amalgam wast( required to use a licensed hazardous waste transporter.Some amalgam sep provide shipping services as part of a standard maintenance agreement. Yol facility and/or shipping service can assist you with necessary record-keeping and labeling. Back to Dental Amalgam/Mercury Recycling index Service Center:Dental Amalgam/Mercury Recycling Record-Keeping Requirements Dental practices and facilities need to keep on-site records to demonstrate tl with the Amalgam Wastewater& Recycling Regulations for Dental Facilities 73.00). Records must be kept for at least five.years, coinciding with the peric the certification. These records include: • Maintenance and service records,for the amalgam separator(s), to de manufacturer instructions are being followed. • .Shipping records indicating that amalgam waste has been transporter facility that is approved to accept it. In Massachusetts, the facility nee Hazardous Waste Recycling Permit. • Any other information that the facility has relied on to complete its cer required by 310 CMR 70.00 and 310 CMR 73.00. Back to Dental Amalgam/Mercury Recycling index Service Center:Dental Amalgam/Mercury Recycling For More Information eDEP Online Filing of Certifications Contact Winnie Prendergast: 617-292-5596 or winifred.prendergast@state.ma.us, . Hazardous Waste Disposal/Recycling Requirements Web page or call the Business Compliance Assistance Hotline: i 617-292-5898 Wastewater Treatment&Amalgam Collection/Recycling Requirements http://www.mass.gov/dep/service/dentists.htm 9/21/2010 Dental Amalgam Mercury Recycling MassDEP Page 6 of 6 UunidLi JUn1 uidiui. 617-292=5667 orjohn.reinhardt@state'.ma.us Mercury Pollution, its Health Effects, and,What Massachusetts is Doing Web page Or call the MassDEP.Mercury Hotline: 1-866'-9MERCURY(1-866-963-7287) Massachusetts,Dental Society 508-480-9797 or 800-342-8747 a Naval.Dental Research Institute 'I'Web site Northeast Waste Management Officials Association 7-Web site Back to Dental Amalgam/Mercury Recycling index Contacts•Feedback Related Sites Site Policies•Help Mass.Gov•Energy&Environmental Affairs•Department of Environmental Protection http://www.mass.gov/dep/service/dentists.htm 9/21/2010 �rv.1. 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CH12 +a Report Pollution }: Seattle,WA 98103 { CH15 800-816 4995 CE15 i CE18 4 CE24 t c r I Rebec - - CatchHg'400 Series - 18921 Dellwood Drive, , CatchHg 1000 Series Edmonds,WA 98026 CatchHg 9000 Series 800-569-1088 i I i 3olmete7CInc. Hg5 } 50 Bearfoot Road,Suite 2 V Hg 5 HV Northbarough,MA 01532 ' 508-393-5115 One.V incer Si:rcr.c-Boacrn• s 6210P•ei1 92-5500 Done Internet a�f � j5tart J'�Inbox-Microsoft Outlook Mass DEP..MA DEP.Am...�'f lightship dental-Google i�Health Master Detail-MI �ly 11 10:19 AM _ - R!e Edit VRw Favorites Tools Help PIP t Back - - % F, ( I Search Favorites ]Address ;Mhttp:l/www.mass.gov/depiserviceibmps.htm Go About MassOEP - -- - _ j, Dental Amalgam/Mercury Recycling Program I Public Participation&News ------------ ---- ------ -- ------------ --------- Ali,s Climate Recommended Practices for Handling - Iling Amalgam&,Mercury Wastes - f Water,Wastewater&Wetlands Amalgam Stop! Waste&Recycling Contact Amalgam has,been in contact with the • Don t place any kind 11 } ---- --- patient and includes: of amalgam waste in Toxies&Hazards your biohazard(red) •`teeth containing amalgam from bag,the trash or . Cleanup of Sites&Spills patlentlextractions, " sharps container. • scrap amalgam from patientlold fillings, Service Center chair-side traps,screens,and • Don t rinse traps, • amalgam sludge from vacuum um filters,or screens laws and rules 4 w g g pump over or down the - filters and other amalgam capture permits,reporting&forrns device.: drain or into a waste online services basket. compliance assistance Recommended Practices for Contact f, • Don't disinfect teeth 'Amalgam: ' environmental results program ` or any item contain- ing amalgam with enforcement&appeals ' •,Always use personal protective any method that `I equipment(gloves)when handling grants&financial assistance uses heat. contact amalgam. training&professional . Render teeth containing amalgam • DonY use house " certification noninfectious by chemical means. + (: Store amalgam wastes in separate hold bleach or other , Calendar [ airtight containers labeled"extracted oxidizing cleaner on teeth".) vacuum lines. W Community • Clean or replace screens,traps,or filters • DonY decant liquid in on a regular basis. which amalgam has Online Services ,Clean screens,traps,and filters before cleaning vacuum lines. been stored down Regional Offices g. . •".Recycle all waste amalgam: the drain. i, Report Pollution • Don t rinse tools f Non Contact Amalgam has not been in contact used to place or .carve amalgams_ _k.. Done _ rl d�_ i ;F .Internet d�Start Inbox-Microsoft Outlook I �Mass DEP,.MA DEP Ha I.�lightship dental-Google I �Health Masker Detail Mi _! 10.22 � I File Edit mew Favorites Tools Help !!r l Back - - R Search Favorites ` - % - D L y 11 Address JiM http:frwww.rnass.govidep/servicelbrnps.htrn Go Noll-contact Amalgam has not been in contact I used toTMplace or ' with the patient and includes: carve amalgams overthe drain. • .broken or unusable amalgam capsules, -excess amalgam,and r • empty amalgam capsules from restorative treatment; „ Recommended Practices for Non-Contact. L' Amalgam: 1 r Store amalgam wastes in separate �. airtight containers labeled"extracted + teeth,""scrap amalgam;"'traps,"etc) �• Recycle all waste amalgam Elememal Mercury Stop! 1 Mercury that results from: Don t clean mercury is spills with a vacuum • spills of bulk mercury, cleaner. -• broken thermometers;and • blood pressure units. „ { Recommended Practices for Elemental f Kai cur: • Train staff in spill cleanup procedure s. Always wear nitrile gloves when cleaning i t C up a spill. J y Clean up visible mercury with a spill kit. c - • Place contaminated items in a sealable container labeled"bulk mercury waste" I and send to an authorized recycling Y facilityr J ._Rar�rr..lo_rinirgari hnik.morCunrthcnnnh an__ � Done I—F Internet J pdental &glel� eMiStart Inbox-Microsoft Outlook CrMass DEP MADEP:Ha lightshi JF _ 1 ' i 10:26 AM Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name Important:When filling out A FacilityInformation: ' _ • - forms on the computer,use only the tab key a.Facility Name b. Facility SIC Code c. DEP Assigned Facility ID to move your Cursor-do not d.FacilitySite Address Street No.,Street Name,Street Suffix e. St,Ave,etc. e.Seconds Unit e. Buildin -C,7th Floor use the return ( 9' Secondary ( 9' 9 key. f.City g.State h.Zip Code rab ; i.Facility Mailing Address(If different from the facility site address above)- j.Secondary Unit r k.City I.State m.Zip Code n.Phone Number o.Fax Number , p:Federal Employer Identification Number(FEIN or EIN) k � 4 A-I. Certification Information a.Contact Person First Name b.Contact Person Last Name c.Title d.Telephone Number e.Owner First Name f.Owner Last Name g.Title' h.Telephone Number i.General business description B. Industrial Wastewater and Holding Tank Information Answer all questions, unless you are directed to skip a question. Do not"answer questions that you are directed to skip. i 1. Major sources of industrial wastewater a. ❑ Process wastewater (Check all that apply) b.. ❑ Equipment cleaning wastewater C. ❑ Spent concentrated solution d. ❑ Floor spills or floor drainage e. ❑ Other(S) (Please describe below) Describe major sources 2. Major pollutants in,the industrial wastewater a. ❑ BOD/COD (Check all that apply) b. ❑ Oil & Grease c. ❑ Low/High pH di ❑ Cyanide e.- ❑ Cadmium f. ❑ Chromium' g. El Co h. ❑ Lead ° i • ❑ Nickel Y j. ❑ Silver k. ❑ Zinc 1. ❑ Other(s)(Please describe below) Describe major pollutants OdepOl.doc 12/02 Page 1 of 6 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank L7 � DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name B. Industrial Wastewater and Holding Tank Information (Cont.) 3. Holding Tank ID (If any): 4. Holding Tank Installation Date: (MM/DID/YYYY) 5. Tank Type (Check one box only): a. ❑ Above-ground b. ❑ In-ground 6. Tank Construction Material a. ❑ Steel (Check appropriate box(es)or specify): b. ❑ Concrete C. ❑ Fiberglass d. ❑ Plastic e. ❑ Other(s) (Please describe below) Describe construction material 7. Tank Capacity a. ❑ Less than 3,000 gallons (Check one box only): b. ❑ 3,000 gallons or more B-I. Compliance Information Section-1 General 101 Do you discharge industrial wastewater to ❑ yes=you must cease discharging and a septic system, leaching field, or complete a Return to Compliance Plan cesspool? ❑ no 102 Do you discharge industrial wastewater to ❑,yes—you must cease discharging and a storm drain or to the ground without a complete a Return to Compliance Plan surface water or groundwater discharge permit? ❑ no 103 Is the discharge of your industrial ❑ yes— I have checked with DEP and I am wastewater to a municipal sewer system aware of the restrictions that may apply to feasible? my facility (if your answer is yes to this question, you need to check with DEP for restrictions ❑ no that may apply to your facility before completing this certification) ■dep0l.doc 12/02 Page 2 of 6 Massachusetts Department of Environmental Protection Ll Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) ' Facility Name B-I. Compliance Information (Cont.) 104 Is your facility located in the Zone I or ❑ yes- I have checked with DEP and I am Zone A of a drinking water supply area?, aware of the restrictions that may apply to (if your answer is yes to this question, you my facility need to check with DEP for restrictions . that may apply to your facility before ❑ no completing this certification) 105 Is this certification for an above-ground ❑ yes holding tank? ❑ no -skip to question 301 Section-2 Above-Ground Holding Tank 201 Is this above-ground holding tank ❑ yes constructed or lined with material compatible with your industrial ❑ no-submit a.Return to Compliance Plan wastewater? 202 Is this above-ground holding tank ❑ yes remotely filled or automatically filled? ❑ no-skip to question 203 202a Have you provided an appropriate ❑ yes audio and light alarm system for this above-ground holding tank? ❑ no-submit a Return to Compliance Plan 203 Have you provided appropriate spill ❑ yes containment for this above-ground holding tank? ❑ no-submit a Return to Compliance Plan 204 Have you provided"Non-Hazardous' ❑ yes Industrial Wastewater' labels for this above-ground holding tank? ❑ no-submit a Return to Compliance Plan 205 Was this above-ground holding tank both ❑ yes installed after November 15, 2002 and fabricated on site? ❑ no-skip to question 401 ■dep01.doc 12/02 Page 3 of 6 ■ Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name B-I. Compliance Information (Cont.) 205a Was this above-ground holding '❑ yes —skip to question 401 tank constructed in accordance with engineering plans that were ❑ no—submit a Return to Compliance Plan stamped and signed by a . ;. and skip to question 401 Massachusetts Registered Professional Engineer? Section-3 In-Ground.Holding Tank 301 Is this in-ground holding tank constructed ❑ yes or lined with material compatible with your industrial wastewater? ❑ no- submit a Return to Compliance Plan 4. 302 Is the capacity of this in=ground holding ❑ yes tank greater than 500% of the average daily flow? ❑. no-submit a Return-to Compliance Plan 303 Have you provided an appropriate audio ❑ yes . and light alarm system for this in-ground holding tank? ❑,no-,submit a Return to Compliance Plan 304 Have you provided "Non-Hazardous ❑ yes Industrial Wastewater" labels or signs for this in-ground holding tank? ❑ no=;submit a Return to Compliance Plan t R 305 Was this in-ground.holding tank installed ❑ yes before November 15, 2002? ❑ no -skip to question 306 305a Was this in-ground holding tank ❑ yes- skip to question 401 constructed in accordance with engineering plans that were ❑ no j stamped and signed by a Massachusetts Registered Professional Engineer? Mdep01.doc 12/02 Page 4 of 6 Massachusetts Department of Environmental Protection Ll Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name B-I. Compliance information (Cont.) 305b Will you (or did you)obtain an ❑ yes -skip to question 401 integrity assessment by November 15, 2003, which will be= ❑ no -submit a Return to Compliance Plan prepared by a Massachusetts and skip to question 401 Registered Professional Engineer, for this in-ground holding tank? 306 Was this in-ground holding tank ❑ yes constructed in accordance with engineering plans that were stamped and ❑ no -submit a Return to Compliance Plan signed by a Massachusetts Registered Professional Engineer? 307 Have you provided an appropriate ❑ yes secondary containment for this in-ground holding tank? ❑ no- submit a Return to Compliance Plan Section-4 Record Keeping 401 Do you maintain all holding tank ❑ yes construction and installation records (including all applicable permits) at the ❑ no -submit a Return to Compliance Plan facility? 402 Do you keep and maintain the appropriate ❑ yes operating records, including wastewater shipment, ultimate destination, and hauler. ❑ no - submit a Return to Compliance Plan information at the facility? f ■dep01.doc 12/02 Page 5 of 6 ■ r Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name C. Certification Statement (Note: Complete all required Return to Compliance Plan forms before signing this statement) attest under the pains and penalties of perjury: (Name of responsible official) (i) that I have personally examined and am familiar with the information contained in this submittal, including any and all documents accompanying this certification statement; (ii) that, based on my inquiry of those individuals responsible for obtaining the information,the information contained in this submittal is to the best of my knowledge, true, accurate, and complete; (iii) that systems to maintain compliance are in place at the facility and will be maintained even if processes or operating procedures are changed; and (iv) that 1 am fully authorized to make this attestation on behalf of this facility. I am aware that there are significant penalties including, but not limited to, possible fines and imprisonment for willfully submitting false, inaccurate, or incomplete information." Signature Date(MM/DID/YYYY) Printed Name Title Source of Signatory Authority(Check appropriate box): 1. If a Corporation: a. ❑ President b.. ❑ Secretary c. ❑ Treasurer d. ❑ Vice President(if authorized by corporate vote) e. ❑ Representative of the above (if authorized by corporate vote and if responsible for overall operation of the facility) 2. If a Partnership: ❑ General Partner 3. If a Sole Proprietorship: ❑ Proprietor 4.:If an Institution: Principal Executive Officer 5. If a Municipality or a Public Agency- a. ❑ hPrincipal Executive Officer b. ❑ Ranking Elected Official (Empowered to enter into contracts on behalf of the municipality or public agency) Edep01.doc 12/02 Page 6 of 6 File Edit Co To Favorites Help I all, IY� 0 Back - - u +'� }Search sU Favorites - - 0 JAddress http:jjwww.mass.govideplserviceiregulationsi314cmr05.pdf •®Go (+� � 3_ Want to create online l Save a Copy ,� ° �Is� ��Selects - '- 118% - l:J •�tl _ {� ! '1 *':.t .an.h N.b �[;� I forms? o (a) Effltient Lllilltatlons for At Grolind Water. Pathoseilic Or'_ailisms- shall not be present.ui JJJ a a111oullt�"llfficleIlt To render the zroulld Water detrimental to the public health. safety, welfcire, oi- the ell[irolllllellt. or lllplir the Ilse of file ground water as all actual or potentW source of potable .V.ater. Pathoneilic Orf_ailisins sha11 also not be pl'esentt iil amotuits sufficient to iliterfere;kith the attallllliellt and maiilteliance of the existili, and Iles mlated uses of 1n,droknicnky eollllected do-vagl q-adient.sirface waters. The discllai'ze 11Innot exceed the lllaxilimiTl colltaillillalit.levels set forth ui 310 C_.3VIIt 22.U0:Drirkirla Motu. (b) The Department may establish`eater quality based effhient l ilitations for a poNallt subject to the 111<ixu1111111 coiltailllllallt levels set forth ul 310 C'NVIR 22.00:D.r I!'lic hl o, Mote;.that are more shil_ent di all those specified ui 314 CMR 5.10(3)(a) it such lnllitations are de-e- led necessary ui the Department's best professional judEplielit to protect groluld `haters as all actual or potential source of potable «rater and./ol' Slu'fice waters Of the C o1TII11Oilyt ea.ltll for theirexistnlg and deslzllated Uses. The Department may also establish-water quality-based effluent killtations for other polhitalits as deeilled Ilecessffiy,ili the Depaltimilt's best professioilal ildallelit to protect the'?round llratel' of the C'011llilom.reaMkh for Ilse as all actltal orpotelitial source ofpotable"eater and the slullce waters ofthe C milllionwealth for their etitstlll`_>finer Clesl�latecl ruses as et forth ril 0 3 14 CMR 4.00 fildidfil�14 WithOtlt hillltaflon effluent 111111TatioilS Oil colitaillu-mAs�vllicha.s of 1larch j a 21?. 2009 are lint resa t<atedby310 C:i\4R22.00: Drink:ina WoTer. Tile Department�.�illprollibit the disclmrze of ally ti txic polhitalit for w1lich the EPA or the Departllleilt llas not yet developed a Health Adiisoly and f7r vrhich there is not sufficient data avall lble to the Department for the E estabhslullelit of a. Health.advisory. The Department. illaa.yr establish a. Health Advisory fi r additional toxic pothitalit ,�trllell Sli$lcleilt.data becomes available. (C) JJecial Water(luahtY Based E$hrent.LI1llitatiom for Exlstni'a Dlscll<al''_es To Oround Water _ Previouslu Cllssiied as C)iiss III. A discharge that was authorizedin a permit issued by the 15 of 38 LLI ;- Downloaded (0 B); .� :���, unknown Zone TdjStart Inbox-Microsoft Outlook , it)http:Jjwww.mass.govjd... 3:09 PM Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID Return to Compliance Plan or Facility Name Holding Tank ID(If any) Important: Instructions When filling out forms on the computer,use 1. Complete a separate Return to Compliance Plan for EACH compliance question answer that only the tab key requires one. (Make extra copies of this form if necessary) to move your cursor-do not 2. Only submit the Return to Compliance Plan(s)for violation(s)that you were unable to correct use the return key. BEFORE the required submittal date. 3. Completing this form does not relieve the facility of its responsibility to operate in compliance with applicable regulations. Failure to operate in full compliance with the applicable regulations may result in enforcement actions that may include fines or penalties. Return to Compliance Plan 1. What is the Compliance Question number for which you are reporting non-compliance? Question number 2. What is the specific non-compliance problem? Brief Description of the Problem 3. What corrective action will you take to return to compliance? . l Describe Corrective Action 4. What is the anticipated return to compliance date? MM/DD/YYYY Responsible Official's Signature ht-rtc.doc 12/02 Page 1 of 1 l ' f Application for Site Plan Review °' SPA _ Date LOCATION Business Name: Lightship Dental Subdivision Plan Assessor's Map# 119, Parcel# 079 ANR Plan Property Address: `1304 Main Street Site Plan Osterville, MA 02655 OWNER OF PROPERTY APPLICANT Name: Eben, LLC Name:• Lightship, LLC Address: P.O. Box 659. Address: 3854 Falmouth Road Cotuit, MA 02635 Marstons Mills,'MA 02648 ; Telephone: Telephone: Fax: Fax: ARCHITECT/DEVELOPER/CONTRACTOR/ENGINEER AGENT/ATTORNEY Name: Sullivan Engineering, Inc. Name: :Darah Schofield Address: P.O. Box 659 Address: Nutter McClennen'&Fish, LLP Osterville, MA 02655 1471 Iyannough Road, P.O. Box1630 Telephone: 508.428.3344 Telephone: 508.790.5400 Fax: 508.428.3115 Fax: 508.771.8079 STORAGE TANKS(HAZ MAT/FbEL OR WASTE OIL) ZONING DISTRICT CLASSIFICATION Existing 0 Proposed 0 District BA Overlay(s) WP . Number Number: Lot Area 56,630 Sq. Ft.' 1.3 Ac. Size Size Fire District COMM Above Ground Above Ground Underground Underground Set backs (ft)`. Contents Contents Front: 20 _ Side: .29.8 Rear: 11 Number of Buildings Existing: 2 Proposed 1 f UTILTTIEs Demolition 1 Private Per Permit Sewer ❑ Public xA Size 737 gal No. 99-164 Water x Public ❑ Private TOTAL FLOOR AREA BY USE Existing Proposed Electric ❑ Aerial x Underground -: (s .ft) (sq.ft.) Gas x Natural ❑ ❑ Propane Basement 0 0 Grease Trap ❑ Size .1060 to be removed- gal _ Residential 0 0 Sewage Daily Flow* - 429 proposed total gpd Restaurant 1344' 0 Retail 0 . 5812 *GP or WP areas restrict wastewater discharge to 330 Office 0 0 gallons per acre per day into on-site system. Dental Office 01 6609 Commercial(contractors office) .581 0 PARKING SPACES CURB CUTS Wholesale(specify) 0 0 Required 29 Existing 0 Institutional(s ecify) 0 0 Provided 30 Proposed 0 Industrial (specify) 0 0 On-Site 30 To Close 0 All Other Uses On Site 0 5723• Handicapped 2 Gross Floor Area 1925 7762 Estimated Project Cost: Fee: $ Over$250,000 $ 500, ' Living area per Assessor's Records. z Accessory building proposed.for use as 581 s.f. retail space or 387.5 s.f. office space;as per plans. s Unfinished basement area utilized for infrastructure/mechanical equipment: Old King's Highway Regional Historic District File# Approved? ❑ Yes x No Hyannis Main Street Waterfront Historic District File# Approved? ❑ Yes x No Listed in National and/or State Register of Historic Places:. ❑ Yes x No Previous Site Plan Review File# Approved? ❑Yes x No Previous Zoning Board of.Appeals File# Approved? ❑ Yes x No Is the site located in a'Flobd Area(Section 3-5.1) ❑ Yes x No In Area of Critical Environmental Concern? ❑ Yes x No Is the Project within 100' of Wetland Resource Area? ❑ Yes x No Site sketch-informal presentation ❑ Yes x No Site Plan prepared, wet stamped and signed by a Registered PE and/or PLS. x Yes ❑ No Parking and Traffic Circulation Plan x Yes ❑ No Landscape Plan and Lightning Plan x Yes ❑ No Drainage Plan with calculations and Utility Plan x Yes ❑ No Building Plans, (all floor plans, elevations and cross sections) x Yes ❑ No Note that all signage must be approved by Code Enforcement Officer at the Building Department Lot area in sq. ft. 56,630 sq. ft. Total Buildings(s) footprint ' 3793 sq.ft. Maximum Lot Coverage as % of Lot 6.7 % GROUND WATER PROTECTION OVERLAY DISTRICT REQUIREMENTS: OVERLAY DISTRICT(S): WP Lot Coverage (%) Required <50% Proposed 22% Site Clearing (%) Required <70% Proposed 32% PRINCIPAL BUILDING ACCESSORY BUILDING(S) x Yes ❑No Number of floors: 2 Height: 16 ft. Number of floors: 1 Height: ft. FLOOR AREA: 7181 FAR: N/A FLOOR AREA: 581 FAR: N/A Basement 2966 sq. ft. Basement 0 sq. ft. First 3077 sq. ft. First 581 sq. ft. Second 1138 sq. ft. Second 0 sq. ft. Attic 0 sq. ft. Attic 0 sq. ft. Other(Specify) 0 sq. ft. Other(Specify) 0 sq. ft. Please provide a brief narrative description of your proposed project. The Applicant proposes redevelopment of the site by demolishing the existing restaurant building and constructing in place thereof an approximately 7,181 square foot.dental office for two practicing dentists;together with 30 parking spaces and associated site improvements. The existing 581 square foot commercial structure to the East of the proposed dental office will be retained and utilized as a 581 square foot retail space or 387 square foot office (with the remainder of the building used for storage): The total wastewater flow from the redeveloped site will be limited to 429 gpd. The proposed uses.and site design are fully consistent with' requirements.of the BA Zoning District and no zoning relief is anticipated.J I assert that I have completed (or caused to be completed) this page and the Site Plan Review Application and that, to the best of my know dge, the information submitted here is true. CR Si nature o A plicant Date �.� a �.�.�C �cCCQ�nen� �Sln,l�.e Printed Name of Appl cant i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a Ricky L.Wright- Certified Title V,Inspector,508-477-0653 TITLE 5 'OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1340 Main Street,Ostervitle,MA 02655 Owner's Name: EBEN LLC C/O Joan Bentnick-Smith Owner's Address: 1340 Main Street Osterville,MA 02655 w Date of Inspection: April 14,2009 Name of Inspector:Ricky Wright License#S14595 Company Name: B&B Excavation,Inc. Mailing Address: 14 Teaberry Lane - Forestdale,MA._-02644 Telephone Number:508-477-0653 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 the-inspection.The'inspection was performed based on my training 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: ZZ, The system inspector shall submit 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 ofthe 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: The information as identified represents only the condition of the system on April 14,2009 at 1:00 PM. ****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. L"A q 01 o . Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART A CERTIFICATION (continued) Property Address: 1340 Main Street,Osterville,MA 02655 Owner's Name: EBEN LLC C/O Joan Bentnick-Smith Owner's Address: 1340 Main Street Osterville,MA 02655 Date of Inspection: April 14,2009 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or m310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: NA 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. 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: 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 (THIS IS REQUIRED TO BE COMPLETED) 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)ate replaced obstruction is removed ND explain: Page 3 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1340 Main Street,Osterville,MA 02655 Owner's Name: EBEN LLC C/O Joan Bentnick-Smith Owner's Address: 1340 Main Street Osterville,MA 02655 Date of Inspection: April 14,2009 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 CMR15.303(1)(b)that the system is not functioning in a manner:which will protect public health,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 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: _ 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. The system has a septic tank and SAS and the SAS is within a Zone 1 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 100 feet but 50 feet or more from a private water supply 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 lie attached to this form. 3. Other:The primary cesspool is not a typical configuration for a cesspool. It appears to be a pipe cylinder with an inlet pipe and outlet pipe with tee connected to a pre-cast 4'deepx6'diameter leach pit with stone. Permit on file with the BOH for the pre-cast leach pit. "T1rT!'7T♦T TA,TCi71T,T!',TTlIA.TT/\TllLd 1CT/\1V Wd%" T7l%T TTATT♦",%7 A 0C11VVC1AT1r1kTnr0 Page 4 of 11 PART A CERTMCATION(continued) Property Address: 1340 Main Street,Osterville,MA 02655 Owner's Name: EBEN LLC C/O Joan Bentnick-Smith Owner's Address: 1340 Main Street Osterville,MA 02655 Date of Inspection: April 14,2009 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X— Static liquid level in the distribution box above outlet invert due to an overloaded.or clogged SAS or cesspool _NA _ Liquid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. — X__ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ 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.] _NO (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: NA To be considered a large system the system must serve a facility with a design flow 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) yes 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 the system is located in a nitrogen sensitive area(Interim Wellhead.Protection Area—IWPA)or a mapped Zone n 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 "yes"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 1 C 1AA 7%. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1340 Main Street,Osterville,MA 02655 Owner's Name: EBEN LLC C/O Joan Bentnick-Smith Owner's Address: 1340 Main Street Osterville,MA 02655 Date of Inspection: April 14,2009 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X_ Were any of the system components pumped out in the previous two weeks X_ Has the system received normal flows in the previous two week period? X_ Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? X_ _ Were all system components,excluding the SAS,located on site.- -X— _ 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? _X_ 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 X Existing information.For example,a plan at the Board of Health. _X_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS f Page 6 of 11 PART C SYSTEM INFORMATION Property Address: 1340 Main Street,Osterville,MA 02655 . Owner's Name: EBEN LLC C/O Joan Bentnick-Smith Owner's Address: 1340 Main Street Osterville,MA 02655 Date of Inspection: April 14,2009 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 3 of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no): Seasonal use:(yes or no): Water meter readings,if available. Sump pump(yes or no): Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment:_Catering Business Design flow(based on 310 CMR 15.203): 550 gpd Basis of design flow(seats/persons/sgft,etc.):_21 seats Grease trap present(yes or no):_Yes Industrial waste holding tank present(yes or no): No Non-sanitary waste discharged to the Title 5 system(yes or no):_No_ Water meter readings,if available:_not available Last date of occupancy/use:_2/09 OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): no If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: . TYPE OF SYSTEM _X_ Septic tank,distr.box,soil absorption system(4/500 gal chambers,1000 gal grease trap,1500 gal tank) _Single cesspool Overflow cesspool Privy No Shared 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 obtained from system owner) Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date'installed(if known)and source of information:Approx. 10-15 years Were sewage odors detected when arriving at the site(yes or no) No OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS Page 7 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 1340 Main Street,Osterville,MA 02655 Owner's Name: EBEN LLC C/O Joan Bentnick-Smith Owner's Address: 1340 Main Street Osterville,MA 02655 Date of Inspection: April 14,2009 BUILDING SEWER(locate on site plan) Depth below grade:Approximate;3 feet . Materials of construction:_cast iron X_40 PVC other(explain): Distance from private water supply well or suction line:greater than 100' Comments(on condition of joints,venting,evidence of leakage,etc.): At time of inspection,sewer pipe wag in good shape SEPTIC TANK:N.A.(locate on site plan) Depth below grade:4 feet Material of construction:X_concrete metal_fiberglass_polyethylene_other(explain)_ If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 6'X 6'X 11 Sludge depth: 6 inches Distance from top of sludge to bottom of outlet tee or Baffle: 4 feet Scum thickness:none Distance from top of scum to top of outlet,tee or baffle:no scum Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Actual measurements with tape and scour stick. Condition of tank(inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.) at time of inspection,tank tees were all in.good condition GREASE TRAP: N.A. Depth below grade:_1 foot_ Material of construction:X concrete : metal _—fiberglass_polyethylene—other (explain): — — Dimensions:_5'X 5'X&5 Scum thickness:_2 inches Distance from top of scum to top of outlet tee or baffle: 10 inches Distance from bottom of scum to bottom of outlet tee or baffle: 3`feet Date of last pumping:_unknown Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):At the time of inspection,tank looked structurally sound— liquid levels were good and all tees were in place OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r - • Page 8 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 1340 Main Street,Osterville,MA 02655 Owner's Name: EBEN LLC C/O Joan Bentnick-Smith Owner's Address: 1340 Main Street Osterville,MA 02655 Date of Inspection: April 14,2009 TIGHT or HOLDING TANK: NA._(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no):. Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) . Depth of liquid level even with outlet invert: liquid level is above the outlet invert. 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.):D-Box is decayed an structurally unsound. Evidence of solid carryover. Tank,is crumbling in place.No signs of backup—structurally sound . PUMP CHAMBER:,(locate on site plan) NA 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.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS O'Ninoo➢'Tf%W9,j/"O 00117 d"T W%1rV",r%0 1 T 01701VT1►A Tl►To"in./'�TTl�I►T 1 d%"1L9 Page 9 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 1340 Main Street,Osterville,MA 02655 Owner's Name: EBEN LLC C/O Joan Bentnick-Smith Owner's Address: 1340 Main Street Osterville,MA 02655 Date of Inspection: April 14,2009 SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type X_leaching pits,number 1 X_leaching chambers,number: 4 _leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions_ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etch No ponding on ground. No excessive growth of vegetation. Did not expose leach pit due to conditions found in distribution box. CESSPOOLS:_(cesspool must be pumped as part of inspection)(locate on site plan)NA Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: 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.): PRIVY:_(locate on site plan)NA Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 10 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 1340 Main Street,Osterville,MA 0285 Owner's Name: EBEN LLC C/O Joan Bentnick-Smith Owner's Address: 1340 Main Street Osterville,MA 02655 Date of Inspection: April 14,2009 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. . Regr o -Bu i Id i n Of I; -5 Tq 2 NK C>v A 1 = 28•6 • 7— 8 D 75oy a l " zz . A2 - 54,6 B2 = 5 "1 5 Li' A 'S _ 6 9.4p B3 = 71 ' 3 I Le Gch Cho,m be x 13 A 4 7 9 % N A- 71.4 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS CITT"CITT"IM♦ CITT1117♦d"JT F%TC41nd'%40 ♦T C1t7CYTT1L,T T1CTC1""J 1TT/11►T lr^"IkR -+ / f Page 11 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 1340 Main Street,Ostervlle,MA 02655 Owner's Name: EBEN LLC C/O Joan Bentnick-Smith Owner's Address: 1340 Main Street Osterville,MA 02655 Date of Inspection: April 14,2009 SITE EXAM Slope 2% Surface water NA Check cellar (crawl space)YES Shallow wells NA Estimated depth to ground water_feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: _X Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board ofHealth-explain:Recent Test Holes, Existing engineer records with BOH Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Based on information in the Board of Health the ground water in the area appears to be approx. 10'below.grade. �e nI dam- VIA" s rN+ Town of Barnstable (� �OFT"E'O�ti* 200 Main Street, Hyannis, Massachusetts 02601 • �^B Growth Management Department JoAnne Buntich, Interim Director ' �•� 367 Main Street Hyannis,Massachusetts 02601 ptED µp'l A Phone(508)862-4785 Fax(508)862-4725 www.town.barnstable.ma.us May 29, 2009 Lightship Dental LLC c/o Attorney Eliza Cox Nutter McClennen& Fish P. 0. Box 1630 Hyannis, MA 02601-1630 Reference: Site Plan Review # 011-08 - Lightship Dental f1304-1Vlain Street, Ostiervil, Portion of Map 119,Parcel 079 by ANR Proposal: Redevelopment of site by demolishing existing building and constructing 7,181 s.Udental office, associated parking and site improvements. 387 s.f. of existing 581 s.f. commercial structure use for retail/office balance of s.f. storage. Wastewater flows limited to 429 gpd. Dear Sir/Madam: Please be advised that subsequent to the formal site plan review meeting of April 9, 2009 and further discussion with Growth Management Engineer and COMM Fire Department, the above proposal has received an administrative approval subject to the following: • Approval is based upon plans entitled, "Site Plan Existing Conditions/Proposed Improvements at 1304 Main Street, Osterville, MA, 2 sheets"prepared by Sullivan Engineering, Inc., Osterville, MA for John R. Lake, Jr, DDS, Marstons Mills, MA and dated 3/19/09, sheet 2 revised 4/21/09 per SPR Committee comments regarding parking lots and drainage changes, with final revision 5/08/09 and Landscape Plan L4.01 by Centerline Studios, Inc. dated May 11, 2009. Said final plans depict the modification of entrance to the primary parking lot in order to retain an existing mature tree, and relocation of bio-infiltration drainage basins to the rear of the property for improved aesthetics along Main Street. • Compliance'with proposed flows of 429 gpd or less as set forth in Title 5 Wastewater Flow chart submitted to site plan review file will be necessary. • Applicant must obtain and comply with all other applicable permits, licenses and approvals required. • Upon completion of all work, a registered engineer or land surveyor shall submit a letter of certification, made upon knowledge and belief in accordance with professional standards that all work has been done in substantial compliance with the approved site plan (Zoning Section 240-104 (G). This document shall be submitted prior to the issuance of the final certificate of occupancy. Sincerely, r Ellen M. Swmiarski, SPR Coordinator, CC: Tom Perry,Building Commissioner.' SPR File Health Departmpt i ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form - Not for Voluntary Assessments 1304 Main Street,Osterville MA 02655 _ Property Address V EBEN LLC. _ Owner Owner's Name required for information is PO Box 710, Cotuit MA _ 02635 August 12, 2008 required — . every page. City/Town State Zip Code 'Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered.in any i way. {. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key j to move your Patrick M. O'Connell cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. Company Name rob 189 Cammett Road Company Address Marstons Mills MA 02648 ,ertm Cityl-rown State Zip Code 508-428-1779 SI 12855- . Telephone Number License Number B. Certification 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 the inspection. The;inspection t was performed based on my,training and experience in the proper function and mWMtenance<of on site sewage disposal systems. I am a DEP approved system inspector pursuant to` bction 15 340 of Title 5 (310 CMR 15.000). The system: CD ® Passes ❑ Conditionally Passes ❑ Fails {^? co C-r1 ❑ Needs Further.Evaluation by the Local Approving Authority August12 2008 Inspector's Signature Date The system inspectorshall submit 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. - ****This report only describes.conditions at the time of inspection and under the conditions of use at that time. This inspection does notaddress how the system will perform in the future under the same or different conditions of use. I 08-212 EBEN LLC.doc•08/66 Title 5 Official Inspection form Subsurface Sewage Disposal System•Page 1 of 15. Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments' 1304 Main Street.Osterville MA 02655 Property Address EBEN LLC. Owner Owner's Name information is PO Box 710, Cotuit MA 02635 August 12, 2008 required for every page: City/Town State Zip Code Date of Inspection B. Certification (cont.) b Inspection Summary: Check-' A,B,C,D,or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described } in 310 CMR 15.303 or in310 CMR 15.304 exist. Any failure criteria not evaluated are i indicated below. Comments: i Recommend pumping tank, leaching chambers have 6-8 of standing Water with no high stains. i B) System Conditionally Passes: ❑ One or more system components as described in,the"'Conditional Pass" section need to be j 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. ❑ 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: ❑ Observation of sewage backup or.break out or high static water level in the distribution box due to broken or obstructed pipe(§) 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 08-212 EBEN LLC.doc 08/06 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 , I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1304 Main Street, Osterville MA 02655 Property Address EBEN LLC, Owner Owner's Name information is PO Box 710, Cotuit MA 02635 -August 12, 2008 " required for every page. City/Town State Zip Code' Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.) ❑ 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: 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'orthe environment. 1. System will pass unless Board of Health.determines in accordance with 310 CMR . 15.303(1)(b)that the system'is not functioning in a manner which will protect public health, 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 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;. ❑ 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. ❑ The system has aseptic tank and SAS and the SAS is within:a Zone 1 of a public water 5 supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water " supply well. 1 i Page 3 of 15. 08-212 EBEN LLC.doc•08/06 _ Title 5 Official Inspection Form:Subsurface Sewage 0isposat System• i l- i i -Commonwealth of Massachusetts w Tithe 5 Official Inspecfion Form f' Subsurface Sewage Disposal System..Form =Not for Voluntary Assessments. 1304 Main Street; Osterville MA 02655 Property Address EBEN LLC. Owner Owner's Name information is PO Box 710, Cotuit MA 02635 August 12, 2008' required for i every page. City/Town State Zip Code-. Date of Inspection B. Certification (cont.) C) Further Evaluation is.Required by the.Board of Health (cont.): l ❑ The system has a septic tank and SAS.and the SAS is less than 100 feet but 50.feet or . more from a private water supply well**. , i Method used to determine distance: ** This system passes if the.well water.analysis,-performed at a QEP certified laboratory, for coliform bacteria indicates absent.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: i - D) System Failure Criteria Applicable.to All Systems: : You must indicate "Yes" or "No" to each of the following for all inspections: Yes No Backup into facility p of sewage g or system component due to 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_day flow Required pumping more than 4;times in the last year NOT due to clogged or El ® obstructed pipe(s). Number of times pumped: ® Any portion of the SAS,.cesspool or privy is below high ground water elevation. ❑` ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 08-212 EBEN U-C.doc•08/06 Title 6 Official Inspection Form Subsurface Sewage Disposal System,-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1304 Main Street, Osterville MA 02655 Property Address EBEN LLC. Owner Owner's Name i information is PO Box 710,Cotuit MA 02635 August 12, 2008 I required for — eve page. City/Town State every Zip Code Date of Inspection j - B. Certification (cont.) i D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system.is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. ❑. ® The system fails.1 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 flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either''yes" or"no" to each of the following, in addition to the questions in Section D. Yes 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 ❑ Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone lI 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 yes' 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: 08-212 EBEN LLC.doc•08/0.6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 15. t I Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1304 Main Street, Osterville MA 02655 Property Address — EBEN LLC. Owner Owner's Name information is PO Box 710, Cotuit MA 02635 August 12, 2008 required for — every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" 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 flows in the previous two week period? ` ❑ ®. Have large volumes of water been introduced to the system recently or as part of this inspection? ® ElWere as built plans of the system obtained.and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs.of break out? ® ❑ Were all system components, excluding 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? I Was the facility owner(and occupants if different from owner) provided with ® information on the proper maintenance of subsurface sewage disposal systems? i The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example,'a plan at the Board of Health. ® Determined in the field (if any of-the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR-15.302(5)] :i I , 1 I l 087212 EBEN LLC.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts N Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1304 Main Street, Osterville MA 02655 Property Address — EBEN LLC. Owner Owner's Name — information is required for tate p0 Box 710, Cotuit MA 02635 August 12, 2008 - every page. City/Town : S Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of.bedrooms (actual): — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): Number of current residents: = Does residence have a garbage grinder? "❑ Yes ❑ ,No, j Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑` Yes ❑ : No Seasonal use? ❑ Yes ❑ No i Water meter readings, if available (last 2.years usage (gpd)). — Sump pump? - ❑ Yes ❑ No t - Last date of occupancy: sate j Commercial/Industrial Flow Conditions: Resturaunt Type of Establishment: Design flow (based on 310 CMR 15.203)` 717 gg d. Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft.,'etc.): 21 seats x 35 gpd/seat= 735 gpd. Grease trap present? . _ ® Yes ❑ No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: 234,000 gal:_320 gpd.. Last date of occupancy/use:. Currently Occupied 'Date Other(describe): -= -=-------- --- =_ 08-212 EBEN LC L .doc•08/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System Page 7 of 15 i Commonwealth of Massachusetts Title 5 Offic.ical Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1304 Main Street, Osterville MA 02655 Property Address -- EBEN LLC. : Owner Owner's Name - information is PO BOX 710, Cotuit MA 02635 August 12,2008 _required for g every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information. I Pumping Records: . None. Source of information: - Was system pumped as part of the inspection?. ❑ Yes ® No If yes, volume pumped: gallons .. How was quantity pumped determined?' — Reason for um in P p g: Type of System. ® Septic tank, distribution box, soil'absorption system ' El Single cesspool ❑ Overflow cesspool Privy ❑ Shared 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_obtainod,from system.owner) - Tight tank. Attach a copy,of the DEP approval. Other(describe):. Approximate age of all components, date installed (if known) and source of information. Orig. system: 1995, Grease Trap: 1.998, Additional Leaching Chamber: 1999 Were sewage odors detected when arriving at-the site? ❑ Yes 'No 0 -212 EBEN LLC.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fornn Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1304 Main Street, Osterville MA 02655 { 4 Property Address I'I EBEN LLC. _ Owner Owner's Name information is PO Box 710 Cotuit MA 02635 August 12, 2008 , required for — every page. Cityrrown State Zip Code Date of Inspection I i D. System Information (cont.) Building Sewer(locate on site plan)' Depth below grade: feet i Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage,etc:); 1. . I Septic Tank (locate on site plan): , Depth below grade: feet i Material of construction: ® concrete ❑metal ❑ fiberglass ❑ polyethylene .❑ other.(e.xplain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach:-a copy of certificate) ❑. Yes ❑ . No -- ----------'------------- --`---------- - ---- ----- - - ------------ --- --- ------- -.----------------- Dimensions: 10.5' long x 5 8'wide- 1500 gal, Sludge depth:, — jDistance from top of sludge to bottom of outlet tee or baffle 26:-- -- Scum thickness. 6 Distance from top of scum to top of outlet tee or baffle101, — —= -- I Distance from bottom of scum to bottom of outlet tee or baffle - --- — -- How were dimensions determined? Measured OB-212 EBEN LLC.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 0=15 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1304 Main Street, Osterville MA 02655 Property Address — EBEN LLC. Owner Owner's Name — inf Drmation is PO Box 710, Cotuit 02635 required for August 12, 2008 ev ry page. Cityfrown State Zip Code Date of Inspection i D. System Information (cost.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid.levels as related to outlet invert, evidence of leakage, etc.): i - Grease Trap (locate on site plan): Depth below grade:. 2; feet Material of.construction: ® concrete ❑ metal`. ❑ fiberglass' ❑ polyethylene ❑,other(explain): - Dimensions: 1000 gala 12" Scum thickness — 8 Distance from top of scum t top of outlet tee or baffle o Distance from bottom of scum to bottom of outlet tee or baffle 24 — Date of last pumping: Unknown Date Comments(on pumping recommendations, inlet and:outlet tee or baffle condition; structural integrity., liquid levels as related to outlet invert, evidence.of leakage, etc.): Liquid level was found at bottom of outlet invert, tees are intact and clear. n 1e la ' Tight or Holding Tank tank must be pumped at time of inspection) (locate 0 S t n • 9 .. 9 ( p. P Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): I. i 212 EBEN LLC.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 15 a 1 . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1304 Main Street, Osterville MA.02655 Property Address EBEN LLC. Owner Owner's Name informationdf is PO Box 710, Cotuit MA 02635 August 12, 2008 re uired for _ g e ry page. City/Town State:- Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) i Dimensions: — Capacity: — gallons Design.Flow: gallons per day Alarm present: El Yes ❑ No Alarm level: Alarm in working order: El Yes ❑ No Date of last pumping: --- — Date. Comments (condition of alarm and float switches, etc.): - *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑.,No Distribution Box (if present must be opened) (locate on site plan): 011 Depth of liquid level above outlet invert 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.): No solids or high stains present, liquid level was found at bottom of outlet pipes. Pump Chamber,(locate on site plan): Pumps in working order: ❑ Yes ❑ .No - Alarms in working order: ❑ Yes ❑ No 0 -212 EBEN LLC.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1304 Main Street , Osterville MA 2 0 655 Property Address P Y EBEN LLC. Owner Owner's Name -- inlormation is fo reuired for p0 Box 710, Cotuit MA _ .02635 August 12, 2008 e ery page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition'of pumps and appurtenances, etc.): . Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why' Type ❑ leaching pits number: ® leaching chambers. number: Four 500 gal drywells. ❑ Teaching galleries number. ❑ leaching trenches_ number, length; ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: --- - — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Observed 6-8" of standing water in chambers with no high stains. 0 7212 EBEN:LLC.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15- r Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1304 Main Street, Osterville MA 02655 Property Address — EBEN LLC. Owner Owner's Name information is PO Box 710, Cotuit MA 02635 A_u ust 12, 2008 re uired for g every page. City/Town State Zip Code Date of Inspection. : D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert — Depth of solids layer Depth of scum layer Dimensions of cesspool - Materials of construction Indication of groundwater inflow, ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 1 i - 8-212 EBEN LLC.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 • :Commonwealth of.Massachusetts f Title 5 Officials Inspection F®rm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1304 Main Street, Ostervllle MA 02655 Property Address - EBEN LLC. caner Owner's Name i formation is PO Box 710,.Cotuit MA 02635 August 12; 2008 equired for — -...-----_.._ . ...... _ _.. -- --- very page CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including_.tie to at least two permanent reference landmarks or benchmarks. Locate all.wells within 100feet. Locate where public water supply enters the building. r l 28 2 59 • " 5. 54 , 1 . . . i � .. . , 7 y - . . . . . :, �'ave� Parking Lot , .Commonwealth of Massachusetts Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1304 Main Street, Osterville MA 02655 Property Address — EBEN LLC. O ner Owner's Name rreui�ed ui-red for on is PO Box 710, Cotuit MA 02635 August 12.2008 i every page. Cityrrown 'State Zip Code. Date of Inspection • D. System Information (cont.) j Site Exam: l ® Check Slope ® Surface water ® Check cellar ®Shallow wells Estimated depth to groundwater: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health.- explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -'explain: You must describe how you established the high ground water elevation: i Low area on opposite side of road with no surface water is considerably'.lower than bottom of SAS. 08-212 EBEN LLC:doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable ��p THE 1p�y Regulatory Services` ,AxtsrAB,E, ; Thomas F. Geiler,Director MASS9^ 1 °TEa �A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. 16 addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTICTisclaimer Private Septic I'nspectionSBOC