Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0020 SCALLOP PATH - Health
20 Scallop Path Osterville _ / A= 070-010-002 / D b r 010 00 a-- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel Mellon Owner Owner's Name information Is required for every Osterville Me 02655 2/26/2018 per, Ctyfrmn State Zip Code Date of Inspection Inspection results must be submitted on this form:inspection forms may not lie altered in any way.Please see completeness checklist at the end of the form. i Important:When A. General Information / ( a 6 9.3 Ming out forma on the computer, use only the tab 1. Inspector: . key to move your cursor-do not Sean M.Jones ` use the return Name of Inspector key. S•M.Jones Title V Septic Inspection Company Name 74 Belden ln. - Centerville Me 02632 Cmtylrown State Zip Code 774-248-4850 smjonestitle5Qgmail.com SI4522 Telephone Number lloense 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 was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.)am a DEP approved system inspector pursuant to Section 15.340 of Tittle 5(310 CMR 15.000).The system: , .n ® passes< .,❑ Conditipnaily Passes Fails ❑ Needs Further Evaluation by th ocal Approving Authority 2/26/2018 Inspector's Signature Date 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 of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable,and theroving authority. P ""This report only describes conditions at the time,Rj inspection and under the conditions of use at that time.This inspection does not address tow.the system will perform In the future under the same or different conditions of use. r f`A r y , !Sine•31m3 . Tift 6 MW WsspeWon Farts:Su msfam Sexape Dbpml System•Page 1 of 17 : Cc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel Mellon Owner Owner's Name Information is required for every Osterville Ma 02655 2/26/2018 page wn Cityrro _ _. state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 20 Scallop Path Osterville is served by a Title V septic system consisting of 3 septic tanks, a 1000 gallon and a 1500 and 1000 gallon in series, distribution box and 31000 gallon precast leach pits. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ 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. Check the box for"yes","no"or"not determined"(Y, N, ND)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 exilltration 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. ❑ Y ❑ N r ❑ ND(Explain below): fte•3113 TRIO 5 OfFdW Mspedion form:Mwrfm sewage OispwW System•Pape 2 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel.Mellon Owner Owner's Name information is Osterville Ma 02655 2/2612018 required for every City/Town State Zip Code Date of inspection page. �Y _ B. Certification (cont.) , ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpstalarms are repaired,._ B) System Conditionally Passes(cont.): ❑ '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 ❑ Y' ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N []' ND(Explain below): 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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. U 1. System win 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 oo feet of a surface water_ ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. cbin�•art a Title 5 MW MgMOM Fan:S $swap 04NO WW n•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel Mellon Owner Owner's Name Information is Ma 02655 2/26/2018 Ostelyille required for every . page. Cityfrown State Zip Code Date of Inspection B. Certification (font.) r 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 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 must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You MW indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility 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 1/6 day flow Sins•W13 71t1e 5 OHldel hupeclkm Form:8tftWtW 8ew10 DISPUM System•Pepe 4 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel Mellon Owner Owners Name information Is Osterville Ma 02655 2/26/2018 squired for every page. Cityr'rown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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. ❑ ® Any portion of a cesspooi,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. rrhis system passes If the well water analysis,performed at a DEP certified laboratory,for fecal collform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S 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. I have determined that one or more•of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design 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 the system is located in a nitrogen sensitive area(Interim Wellhead Protection ❑ 0 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. t5ins 3113 TNb 5 Otridal IrWadon Form:Substrfeoe Sewage Dlspoad System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel Mellon Owner Owner's Nam information is Osterville Ma. 02655 2/26/2018 required for every cityrrown state ZIP Code Date of Inspection Page• 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? ® ❑ Were 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? ® ❑ 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: ® ❑ 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)) 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): 770 gpd_ 15ine-3H3 Title 5 Official Inspection Form;Subsurface Sewage Disposal System Page 6 of 117 Commonwealth of Massachusetts awwo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path Property Address — Estate of Rachel Mellon Owner Owner's Name information isOsterville Ma 02655 2126/2018 required for every • page. cityrrown state Zip Code Date of Inspection D. System Information Description: F Number of current residents: 0 Does residence have a garbage grinder? 0 Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? . ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: 9 Sump pump? ❑ Yes 1Z No Last date of occupancy: vacant owe Commercialfindustrial Flow Conditions: Type of Establishment: - - Design flow(based on 310 CMRA5.203): Gatons per day(gpd) Basis of design flow(seats/persons/sq.R, etc.): , Grease trap presents ❑ 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: t5ft-3113 i Tft 5 MOW(ntl edon Form:Sihs of e Sewepe Olaposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fort-Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel Mellon Owner Owner's Name Information Is Osterville Ma 02655 2/26/2018 required for every page. City/Town state Zip Code Date of inspection D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No if yes,volume pumped: gall lons lons 1 00, 1500 How was quantity pumped determined? size of tanks Reason for pumping: routine maintenance Type of System: ® Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval ❑ Other(describe): t5h%-3N3 Tide 6 D)fieW Irupacbm Faro:Submetaoe Sewage Dlaposal Syeam-Pape 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel Mellon Owner Owner's Name frftrmarequire for Osterville Ma 02655 2/26/204$ _. required for every page. City/Town State T_ip Code Date of inspection D. System Information (cunt.) F Approximate age of all components, date installed (if known)and source of information: unknown ,Were sewage odors detected when arriving at the site? . ❑ Yes ® No Building Sewa;,(locate on site plan): Depth below grade: feet Material of construction; ❑cast iron ®40 PVC ❑other(explain):. Distance from private water supply well or suction line: x Beet Comments(on condition of joints, venting,evidence of leakage,etc.): Joint were ok, no leaks, vented through the roof, Septic Tank(locate on site plan): Depth below grade: 1.5',2%2.5' feet. Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 3 tanks, 1000, 1000, 1500 Sludge depth: "- diins•3113 Title 5 Official inspection Form:Sulmrfm somWo oispoasl System•Pap 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel Mellon Owner Ownet's Nameinkrma ~-- — required for every tion is Osterville Ma 02665 2/26/2018 required CWTown state Zip Code � Date of Inspection D. System Information (cost.) Septic Tank(cost.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? �. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.). All tanks pump at time of inspection, all tank were in good condition with water level even with outlet inverts.All tanks have access cover on risers wihin 6'of grade, steel covers. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass' ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle --- Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 6 Otfi W Inspection Form:Substdaoe Sewage Disposal system•Pape 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Rath Property Address Estate of Rachel Mellon Owner Owner's Name inforequired tion is@Y Osterville Ma 02655 2/26/2018 e. cityrro" state Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(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 per day Alarm present: ❑ Yes ❑ No Alarm level: - -- Alarm in working order ❑ 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 Worm-sna THte s ONttlet hspKuan Form:&bwfface sewage ompow -Pegs i i a 17 Commonwealth of Massachusetts lipTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path _ Property Address Estate of Rachel Mellon Owner Owner's Name information isOsterville requires for every Ma 02655 2/26/2018. page. Cityrrown State Zip Code Date of Inspection D. System Information (cons.) Distribution Box(if present must be opened)(locate on site'plan): Depth of liquid level above outlet invert 0ff 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 was in good condition with 2 inlets and 3 outlets. Cover is on a riser 6"below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order. ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): If pumps or alarms are not in working order, system is a condltional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: tsma•3M3 Tirb 5 ofAdel Inwedon Form:subs naft sewage oispow sydem•pope 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 20 Scallop Path ry Property Address Estate of Rachel Mellon ' Owner Owners Nam information isOsterville Ma 02655 2/26/2018 required for every , page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits a number: 3x1000 ❑ leaching chambers - number. ❑ leaching galleries number: ❑- leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/aftemative system , Type/name of technology: - Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of, vegetation,etc.): s.e.s.consists of 3 precast leach pits.All pits were video inspected fron d-box and found to be dry with no stain lines.' Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and'configurabon 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 54m•3M 3 Title 5 OMdal hapectlon Form:Subsurface sewage otspow system•Paw 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel Mellon Owner owners Name quir on Is re 0sterville Ma 02655 2/26/2018 requiredd for every page. c4frown State Zip Code Date of Inspection D. System Information (cost.) 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.): dins•9Ns Title 5 OA9dai tnspedton Form:Subsurface sewage Dlsposal system•Page 14 of 17 f Commonwealth of Massachusetts low Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel Mellon Owner Owner's Name information is every is required for Osterville Ma 02655 2/26/2018 page_ Citylrown State Zip Code Date of Inspection D. System Information (cost.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 160 feet Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below (] drawing attached separately l i3 110 Oil r T AZ 0 i ID tl 3`+ cz l J .V z� C 3o'I, �q VY ` L 3S C!o ` q ^-7 S' p5' 7 tltO 70 C �7 C 6 37 t5ft•3113 Title 5 016dal tnspedinn Farm:StAntdace Sewage 04osa System•Pap 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel Mellon 0WW owner's Name Inrommation Is Osterviile Ma 02655 2/26/2018 required for every Zip Cade Date of Inspection page. Cdyrrom state D. System Information (cont.) Site Exam: ® Check Slope ® Surface water , ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. 12+ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this inspection Report,please see Report Completeness Checklist on next page. &W•W 3 Title 5 Ofri W Inspeaon Form:Subsufaw Swags Disposal System-Page 18 of 17 C • Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Scallop Path Property Address Estate of Rachel Mellon Owner Owner's Name information is Osterville Ma 62655 2/26/2018 required for every Pap. CitylTown State Zip Coda Date of Inspecon E. Report Completeness Checklist ® Inspection Summary:A; B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to Al Systems),completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file j LrAns W13 Its 6 OrOdal hapectkn Form:Subatafaca Sawaq*Disposal System Page 17 of 17 t LOCATIONS SEWAGE PERMIT 110• VILLAGE INSTA LLER'S NAME i ADDRESS kk OR OWNER ye DATE PERMIT ISSUED �-_e �_� � �( � DATE COMPLIANCE ISSUED � f�• �, L 1 ZZ t1` No..... .0.'..G.`� G�0 Fps...... /.... THE COMMONWEALTH OF MASSACHUSETTS , � Sc �•c�c� BOAR® OF HEALTH ,/p. . /✓--..........OF......�1'JA.2:nl. . 14.PGf Appliratiou for Uiipuual Works outitrurthitt ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: .......n._ ....................... .................................... - � ; hoca' dd ess l/y r //��oit/No. /� y s �. . .. - ' Ow Address nsta ler Address Type of Building Size Lot-----_.'_ _____C_________ q. feet V Dwellingo. of Bedrooms.............. .Expansion Attic Garbage Grinder p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures ...................................................... W Design Flow...... .......gallons per person per day. Total daily flow--------- Z ..................gallons. WSeptic Tank—Liquid capacity/5901.0.gallons Length----------- Width................ Diameter---------------- Depth.............. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No,....../.________ Diameter-----/Z...... Depth below inlet----*.......... Total leaching arear2_G..V....sq. ft. Z Other Distribution box Dosing_tank ( ) ..Percolation Test Results Performed bY t p.....YVIV-I&i-f................................. Date-__// f .,Y_........ a Test Pit No. 1---4Zn----minutes per inch Depth of Test Pit--ZZ........... Depth to ground water.__[V_Qru1-'--.--- fi, Test Pit No. 2....... 2—...minutes per inch Depth-of Test Pitl-J�-'...__...... Depth to ground water---pma- e_i..._.___. a ---------------------------------------------- ------------------------------ ------------------------ --•---------•-----------------•----•--.------------------ 0 Description of Soil....................................................................................................................................... ............................ U --------------------------------------------------------------------------------------------------------------- ----------------------------- ....................................................•--.. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable................................................................................................ -----------------------------------•------------------------------------......------..........••--------•-------------------•--•---•----......---------•- .............................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L-T L p of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' se. by the�ar f health. Signed -----------•-----------•. Date Application Approved BY �� '-- -----•--- ---� .. '- 5 �'te Application Disapproved for the following reasons-------------------------------------------------------------------------------------••------•--•----•----...•. D Ili Date PermitNo......................................................... Issued---- `` ........................ Date s• No..- S-` - .x Fes$...... .... THE COMMONWEALTH OF MASSACHUSETTS' `BOARD OF HEALTH ✓'.l�..G•.l.- e!V...............O F......1�4 A/V S%A P16 }' pliration for Dhipwaal Works Cron.5trurtiun "anti# Application is hereby made for a Permit to Construct ( or Repair ( } an Individual Sewage Disposal System at ca dsaQ, 1) CS S T1 ° l'�1irC9 S - Pjg ------ ------ .•--•-------------------------------......O r r Address a nstaller Address Type of Buildi Size Lot...._F_° ._..Sq. feet �. Dwelling—No. of Bedrooms..............a------------------------Expansion Attic (") Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures . ---•-•----------------------------------------------------- ---------•--•--------------------•--------------•------------ ----------- - - - W Design Flow........ ................•..__..gallons per person per day. Total daily flow.........z_.Z:.�-------_._....._..gallons. WSeptic Tank—Liquid capacit/ _gallons Length................ Width--------------.. Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length........._.._. Total leaching area ...______. sq. ft. Seepage Pit No......�.____.___ Diameter----- Depth below inlet...... ............ Total leaching area __ .___sq. ft. Z Other Distribution box Dosing�tar�k / Percolation Test Results Performed ! S Date // ± ...................................................... ........ W �-_-_minutes per inch Depth of Test Pit.. :........... .__N.o Depth to ground water N__. - Test Pit No. 1_._.. n,C•• - fz, Test Pit No. 2....41—...minutes per inch Depth.of Test Pit_e_7'`.......... Depth to ground water_.. d...._._. -------------------------------- •------------------------------- --------.-- 0 Description of Soil.---------- -•---------------------------------------------------------------------------------------------•--------------------------------------••-•----•.....-•---- x V -•••---•-•••-•••••••-•••-••-••-••---••-----••-•••••-••••--•-•••••--•-•••--••--•---•••-----•-•--•----•-•-••••----------••---•-••••••-----•----•-•-••----•-•--••••••••-•-•-•••-........-•--••............. W M. Nature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------••••••••---••--•-•••-----•••--•--------•-••••-•----•---••--•--........•--•-------•------•••..........----•-•....................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f^IT/•1 1;.•-• the provisions of TT7 5 of the State Sanitary Cod, The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been r"ssue by e r of health. i `..Signed.................................-•--------------••---------•-•------•------------•- ................................ D to Application Approved BY .......... . Date Application Disapproved for the following reasons:..................................:.......................... ................................................... ......................................................................................................................................................................................................... ,(/ Date Permit No......................................................... Issued......:/ ...------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... .. ......OF...... !/...... /'US i! . :.... ....................... �r�gfirtt�r laf �utYt�rli�ttrr `� TFI IS TO R Y, T t the Individual Sewage Disposal System;coristructed ( r Repaired ( ) bY----------- ----• - . -- - ------------....--•......•---....-----.... at..........A �..:�.DI6!1,�►`------. '........." t In '1G�` t'! �2/e/t"1L ' ------------ -------•- has been installed in accordance with the provisions of TI 5 f The State Sanitary .d aas ONcribecj/ application for.Disposal Works Construction Peimit._No....____Q.`��................. dated_--. _____ _____..______�__.___./_.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........-!•----...... ...-.14d.....:...•.......................... ._ .._. Inspector ------:.. :........... --..:--�---1- -- --- -•-1. : ..............•------- THE COMMONWEALTH OF MASSACHUSETTS jRa BOARD OF HEALTH � W...................OF...... .....................................................r" No.. w,.. FEE.... .............. i,srosWIndij rr#' n rr�tit Permission is eby granted • =: .._. '=- <....................... to Construct (. or Repair (//) anewa e Disp sal System at No......... ........... ., G... ..... ..... as shown on the application for Disposal Works Construction r t N . .. _ •_ __. te�d�............ ...... .................. oar --- Heal--•-••• ---•-- ----•-�-------• -.----- q~�............................ .. Board of �Iealth , DATE...--•- ���/// --- ------------------------------- t� FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ,. /1(O7"L= ' /F' E=/-rNER ?'HE. S•.'_=PT/G�7'.� YV %00 FT MIM %' r '//+lG ,PIT' ARE- INJURE CO't✓ER , /O FT M/�✓ `' SAPALL BF 0A?006147-" TO !*RADE. ��;.'✓ EXTRA CONCRETE �g"PYL' P/PEA CiEAvy C/9S?" //2oN-CafiER Sfa.4LL. !3E USED 'V i Al/N. P/TCN I I F/N ,C7R/✓EW4 Y COP, �B PER FT. CONC.QETE ^._ =_ --_ --- GR.40A CU ✓ER CLEAN .SAA/� -- -- -_ - LIQ[j/J LEVEL ut: 2"SAYER . J i..4 - 4"CFST , � o a 7� � + IRO,'d PIPE GAL. 1 • •I • • • • . /a v �„ HASHED S7',�NE P/TCN F :. U/ST. / • • • • • • • 1 • ♦ ry u q %4 PEA �T. = srPrrc rA/VK BOX o Q o , , «. e . . . . . , •°p o � ;e`,` �= c � � 1 1 •EFFECT/VE '. o WASHED, 57aNE �.. w� o rF r / e DEPTH • • 1 ��� v � l P 'ECA5 T SEEPAG E D::..o: ° a s c 1 • a • o • • • 1 . " p °•p /lvveg,7 ELEVAT/OHS G y °. 6 "lYi INVERT AT BU/LD/NG MS F7 }2. FT v/�/r/ C(5ES T�ULAT)010 14 e T .5EA5T/C 7-A IV K _I S, O r r - i 041-tl.ET SEPTIC TANK 14.8 FT c - --- GRouNO WATER TAELE /NLFT G/STR/BUT/ON BOX ! ,4 FT. SECT/ON OF oanETD/5TRI6llT/UN BOX�4.3 FT. SEWAGE O/SPOSA L SYSTEM _ /NLtT LEAC-/iNGt f�IT !4o FT TiiBULATlDN I - LEACH11V6 PST U/HENS/ON A_z ''SFT. S/GIy' GK/TER/R D/HENS/ON B-4— F7. ,V 4,01 -ER of aEDROOMs _Z SOIL LOG GARBA�EDISPOSALUNIT_NO _ SD/L TEST TOTAL E3T/M4TEU f=LOK/_zZ0 GAG.�DAy SOIL TEST lot/ SO/L TES7-#z q tI4/JMBER GF ��CacNcNG: NITS_ r^FLe �6'S �ELl�'¢ DATE OF SOIL TEST _ I� �Z�_�7_L_— ' S/OE LEAGH/ivG PEs� PIT �-5.1_S 7. FT• d RESULTS hI/TNESSED dY '_p• _i3u it///C/S D — Z &rACOLA /ON T RA TO / �Ss M//V//NCH -9UTTUM L�iCH/NG PER l�/T�._�3 - SQ• FT Lo A ^� � LOAM �' � TOTAL LEACHING AREA z 64-SQ �T Sve so IL s v�s.olL RCGLAT/nN RATE. 2 M/N.�INCH . RESF.RYE LEACHING AREA-26�" $Q. F7r... ;:.. r ScAPc//T, Fit l✓£r/Z R O A D 0-97 c S AA(C) P. BUNIKIS• -' ` No.22162 '4 ELOREDOE ENGINEERING COtilNG .0 9 . Z 7/Z MAIN S `, 3 F FLE(/% 4iS EL-: . 1 4 MASy S ... ,. �. ` Y. .: NYANN/J• .MASS_ SO .;: ,. . ® NOGROLJND'%-�j4 61RD UND Lv/I TER i4'l` E4F✓..: .JQB 1�0 .`P " 7NER N _ P ',G�v D�O'7F _ 20 FT . M/N. _I ARE- /'LORE r14 , :v•`12 BEL. p 24"vIANI�TL��' G'O/4/:G:�F_.T� CO' . _._.. ( i S�dALL ®C 9ROUC�a�7TD rF{,4O.E. �•-,,'✓ EXTRA 1 tf"PVC PIPE—` / .< CONCRETE /vJ/N. PITCH NE,4VY CAST /?O/Y•Co/%ER ShrALLn L3E USED /N ✓EtN Y • COKE - � T :. PER F - :. c., f - -- -- �.- -- 4/?•goE/ LEAN .SANO✓,E-f' z L _ C�.r� L/QU/U LEVEL a •,3 >. = ..trT'�, ` —�---- 2 L.4YE i2 4 /R0N P/rE � o , U k �I P/TCN r{ GAL. I UI ST, e U k , oo • • • o r ei p Q 4 wA5NF0 57✓NE PE,4 FT. =i S.CPT/C TA/VK ° ��. r e • • • • o e r o °n uoq BdX 314 + o c c r e e PEP TN ° o o WA5NED STlz QiYE � — aoa • • • 000 � ov� oo . . • � c da a (�' r o of . o o • e e r� � °• PREC,.g57^SEEPAG E 0 80 �{ r ra; v • e seoe e o PI7OR EQU/V:. .� !Nl!e� ELE1/AT/ONS //✓,PERT .4T BUILDING �,S FT. Tf1CULATJON .5c PTIC TANK ,OlJ�`LET SEPTIC TANK FT y i GROUND {HATER TABLE INLET GISTR/c9UT/0N 8OX 4=7 SECT/O/V OF DUTLETDJSTR/BUT/UN BOX_/4.S FT /NLt- r [.EAC iACl 7- _!4 fl FT SE�/.4GE C�IS�'OSA L aSYSTEM TA5l1LAT/ON - LEA CHI/VG PIT IME I j S�.4LEpNSION �lFT. _ DF.5/&N CR TER1AAl , o/�E/vs/oa �_$_Fr�f` NUMBER OF 6EOROOMs Z pf I DJMENS/aN C T. GAR6.'�=QED/SPOSAL UNIT_ NJ _ SOIL TEST TOTAL EST/MATED FLO�(/_z—D GAL.IOAY SO/L.'7EST J / SOIL TEST-*,? _ _ T, I� �2-�_�7�` ' " OIL TESAIUMBER OF . ,DE S/DE LE/a=H//vG PEK P/T _�5.�-_SQ, FT.y ry r /- Z' RESULTS AvITNESSED BY R. P, _130N-1 K1 S 6UTTU/Yt L64Cd//NG PEK /�/T_.�._�-3 SQ. Fr ?��CdLAT/ON I�RTEI LESS M/N. INCH LoANr � LOAM ¢ 'T!-fQ/✓ / TOTAL LEAGN/NG AR6A 2b4 SQ. FT. svB 50/L sv�So/L PiERCOLAT/O/VRATE 2 hJIJV/INCf! RESF.Rl/C E!lC'N/NG AREfI zb q- SQ. FT.: 4 . M E-O/v w► p FF ScAPtJ/T' R I✓S/Z R,c •v o ! / S,4wo :t BUNIKIS+. No.22162 �NGJNAER/NG CO.;IIVc 7/2 MAIN 3=y" 33 NO. MAIN ST OT4b,JN67':-Yr4 �,.EN@'�C%NTc /zL�� NYAN,/vJ�a -MASS SO YARMOUTHe N1ASs a } Gm'o UIV, kl.,ATE�Q : .IC91 Y Ct .7 . OCQT ON 5EW®CIE PERMIT U O. I L L A G F- -0j:-ff-CV a jCk�:-��6 lw —'f QLLERS QWAE,-Se" cLL- ADDRES BlJ1LDER 1�1 L�.LAE ADDRESS ®Ls,TE PERWT 155UED = — — — D &TE COMPLI &MCE ISSUED ; L 2. :L_ 7y-� r housE 3' , ILI �; 1 ti� t 1 4 •� .;axawWtlodangl �,r# ;.� ��^�.-'• TOP fi, x r rl i� ytirr��s ' V Y ' R s ' d •� ��a -js ' i t t{f i, aN y^,,j ,•r N Owl fib 4Z A 3A I'm x I i �C , I' ! 0 1 4,� ,'�rCy flt•. pp �'w .Y y.� ', � Y i�{ �tqT " t t t �a t' s F,.E. I ,�'r �� '�3• � ,� t fix; t t t .!RM 4� r.+ No.------..ff Z_ 4.. Fps..... :................. THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH Ldh.........__.OF.......... ........ .: � �r d.........--......... Appliratinn -for Miipniitt1 Works Tongtrurtion. Vrruift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal system at: (g P ffA 0,S L cation-Address or Lot ---------- -------------------------- t No. -2 �� ------ --- --- -- ---- - --------- --- -- ------------------ _ --- Owner Address. - a --�--- �i �301 m C � - 19taller ddress Type of Building w am ce Size Lot__ ----Sq. feet Dwelling—No. of Bedrooms------7----_.-----. .......................Expansion Attic (Xo) Garbage Grinder (!� aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ----------------------------- - - w Design Flow.. ..................... do .._..` ...._gal ns der erson per day. Total daily flow........�3-aD_-----"-------------gallons, WSeptic Tank2-Liquid capacity)A��ga1 s erigth---- _-__ Width_.____._...._.. Diameter____---_..._._ Depth................... Disposal Trench—No. .................... Width.................... Total Length__________ _ ___ Total leaching area--------------------sq. ft. ,< Seepage Pit No-----3 ..__.......... Diameter...Zo. ....:___. Depth below inlet..... Total leaching area.101-------sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b � � Y-------- ----------�.�e-rA�_.�-'a-------C----0e� --� .----- Date....11�2.�7 y------ -_ 1 Test Pit No. 1-------lad__mmutes per inch Depth of est Pit..-- ............ Depth to ground water----------!_.. ;; .._._.__. w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to grdund'water--------------------- --------------------------- .__ 0 Description of Soil----- tsk,rb " !?erwC" Gr ,/, ----------------------------------------=---------------------------- U , �......................d---------------------------------------------- w U Nature of Repairs or Alterations-Answer when applicable..-------------------------------------------------------I..__-._____.____._._.._._._______----- ----•-- --------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further ees not to place the system in operation until a Certificate of Compliance has 7ben issued by th d of al Signd- i . ............... Cl ............... -------------------------------- Date Application Approved By.--.-!! = --------------------- --- Date Application Disapproved for the following reasons:-----•-------•---........-•-----•--------------------------------------------------------------•------ -------- .....................-...................................................................................----------.........------------------------• •- -- -----------•------------ ---- Date � � Permit No. ss �V Date _ -------------------------------------------------------------------------------------------------------- i, .. x 10......W..ti7t- Fas............................ ' THE COMMONWEALTH OF-`MASSACHUSETTS ripu . ' BOARD O HEALTH , f"IC ''1e :OF � Sfirtttiu t -6r Di-qpuiitt1 Workii Tontitrurtiun . rruid Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual ;Sewage Disposal System at f} .................... � �»'}tom 6.- 4- ------------- ----- ------------------------------------------------ - L c tion-Address or Lot No. 6 a W Owner 3 Address a ......••.. . .._--•-•-•--••----•--•-----------•-----•-------•-- ::F sCallef 'Y Q]� t �__:._: _ /J ddress Type ofBuilding No. o B�rooms..__i.. ° Y ` ize Lot— _ _ S feet e C'ct �.t q Dwelling— Expansion Attic ( arbage Grinder (j :-- --- -- ` Other-Typed of B"uilding ____________________________ No. of persons---------------------------- Showers.( ) — Cafeteria ( ) Other fixtures _ -- r' W Design Flow......................... ............ga ons`per person per day. Total daily flow--------/__3.a�.: ..................gallons. WSeptic Tung-..-Liquid capacit j- -g ; ength-___�--_-'__. Width._ ------ Diameter---....�.------ Depth-.-.m__------ rF -- Width x Disposal Trench—No. ..._y--�^-_._ � _.. Total Length__________._.___. Total leaching area.._..______.____._sq. ft. Total leachino, -irea___ sq. ft. ' ' Seepage Pit No-----3............ Diameter---�p..____....__ Depth below inlet____f�_ ._ a . �a�._..._. 1. z Other Distribution.box'( ) Dosing tank ( ) { a Test Results Performed by---------------- Test `'..... Date_.__�l� 2.11- -------------- Percolation �; Pit No. 1....... ___minutes per inch Depth of est Pit_.__�'�_ __.... Depth to ground water.-__ y;_ _' (� Test Pit No. 2________________minutes per inch Depth of Test Pit-____-_!:_........ Depth to ground water------------------------ -----------------------------•--••---......-------- ------.••-•- •. •......•--:---•...................................................... 0 Description of Soil_--.._�'tr1a. ,q,�_' l x - t6p.. -.----------------------------------------------- -------------- ------------------------ -----------yr- .1--------------------=--------------------=---------------------------------------------- -------------------------•-------------------'--------------------- U Nature of Repairs or Alterations—Answer when applicable.------------------------------------------------------------------............................. t ----------------------- ------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with .the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Complianc been issued by the board of healt Sign ------•-•-•------------• .................................Date W Application Approved By--------- � -•--- -- • "3 7s Date s, Application Disapproved for the following reasons:............................................................-................................................... ------------------...................-.......................-....................... ----------------•---------------------- - Date PermitNo. .......................................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS „ BOARD O HEALT I s y "1............OF........ W �rrtifiratr of OwmV urr << IS IS,TO CP. IF Y `>hat the Individi'al ew Disposal. Syfseconstructed ( ) or Repaired' at' .� r+ r n e has been�m's:talled in accordance,with,.the pr lsions of . rticle XI of The SanitaryAde asp d-esc�ribed in the <�. application fo°r Disposal Works Construction Permit No---------- dated... ._ .,. T1 E ISSUANCE OF TI415` CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE.THAT THE SYSTEM .V1l.ILL FUNCTION SATISFACTORT . :' DATE-------- .............................-------------....................... Inspector ' d THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH t FEE ,. .. at ark �u trurtiuu f rani Permission is hereby gran e ., - .,y _ . a to Co' : uct ( ) epalr ) an Indivi 1 Sew e, posal System = at. ��/� a �: :...... ::... .. as shown on the,application for Disposal Works Construction mit o... ...... ....... DateC�__ *:__ ..........•• _ FORM 1255 HOBBS"& wARREN,. :INC'. PUBLISHERS i i I 1 I I 'i I M __ Town of Barnstable Regulatory Services ��E Thomas F. Geiler, Director 519 Ali Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 To: MELLON,RACHEL L Date Tuesday,February 20,2007 P O BOX 151 UPPERVILLE VA 20185 RE: Underground Storage Tank at: 20 SCALLOP PATH ^ f��1��Q_ Map Parcel: 070010002 Tank NO: 02 Tag NO: 00230 Our records indicate that your underground fuel(or chemical)storage tank is over 30 years old,and has not been removed as required by section 326-3: subsection 2 of the Town of Barnstable Code regarding fuel and chemical storage systems. You are directed to remove this tank within sixty(60)days from the date of this notice. After your tank is removed, please furnish this office evidence in the form of a permit from your local Fire Department within ninety(90)days of the receipt of this notice. You may request a hearing provided a written petition requesting.same is received by the Board of Health within ten(10) days after this order is served. Per Order of the Board of Health Thomas A.McKean,RS,CHO Health Agent Town of Barnstable � NOV Regulatory Services Thomas F. Geiler, Director •� Fa Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 To: MELLON,RACHEL L Date Tuesday,February 20,2007 P O BOX 151 UPPERVILLE VA 20185 RE: Underground Storage Tank at: 20 SCALLOP PATH — 17 t Map Parcel: 070010002 Tank NO: 03 Tag NO: 00231 Our records indicate that your underground fuel(or chemical)storage tank is over 30 years old,and has not been removed as required by section 326-3: subsection 2 of the Town of Barnstable Code regarding fuel and chemical storage systems. You are directed to remove this tank within sixty(60)days from the date of this notice. After your tank is removed, please furnish this office evidence in the form of a permit from your local Fire Department within ninety(90)days of the receipt of this notice. You may request a hearing provided a written petition requesting same is received by the Board of Health within ten(10) days after this order is served. Per Order of the Board of Health Thomas A.McKean,RS,CHO Health Agent COMM, _h LPL Al'. I f. -'j N{ake'application to locai .tire ueparrrsten't. U DDa2, Fire Department retains original application and issues duplicate as Perr-nit. No9fU o�AtAl A_ C'._j`am'.�zfcrey. IL I APPLICAT10ii and PERMIT . for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Seclion 38r'!, 521 CMR 9.00, appiication is hereby m-ade by:. 'Lisa Rockwell , •-- _,.� rae' JrmerPtarrre.(pIodSc print) Can Spring Farms, .X --- -- _ .`rig':IAItXi 7oN;YlAp(i'7 APJirI { _ .. .ost :ill.e MA O2655 Addres^ t C —'�x iJ, erv -- City a1�te' p y Street -- -A -- -- � tom n ttiJme _.. Ent�i.ro=afe Co'_p:_ i •Co.orinrivitlttai Bennett 6 ReiL I pay —�__ �7 ! ! _ Add'ass [IQ ]5 1�T:S`an..rr w r A MA.. 0 2Y,1+ adtl�c�ss i4B Jan aeba.�t are );rxvr - -- satrjc3.wirh, MA I'- Signature(if applying for permit) 6 3ignatzire(if applying tcir permit) r-• i,i IF CI"Csrtli e[ d �Jther:�: __ 13 IFCr Certifled Q LSP# _ Other . Tankl.ocation 1 2 0 sca - o P�� � ` C ,t r Harbors , MA t . , 9,ePP 4carmsa N,! Tank Capacity(gallo,'I ) )+� t; ` T auostawe Last Stored w ! 'ank Di nenalcns(ciarneter x length) -- j ttnttergrouia3 Tan — Vt+ �L '"i.•? /I- '— 1 . Finn trat�sgaorting u'Iaste Etjv,`,o-�-Saf e- Corp- �� ata"e L(c.# �IA#3 29 Hazardous was;eman[fest# M1Q55_5' 4 _ E.P.H. ^_ MAC100001617 _ i M Approved tank dispcsal yarej T iU r n e r , Inc; _ `rank yard#- OU 2 Type of 4iell gas_ _.—��T�;n c v anti sctdress 235 Comm al S= ge e t , Lynn, MA CityY,-Tmvr; Certervi.,.le _ -- -- F D[D#.�01�?C Permit# —— Date of Issue _tarc1m, L006 --- — )ate of expiration A r� 5 2006 —_ y i Dig safe cpl)rc;al nurnoar° _ 2C0610012 2 2_�— Dig Sate Toll Pree Tel.Nurnbt r_800-322-484A i Signature!Title of Officer granting pi�rmit After uE1 oil tanks ex®rTjpted)sand roar,FP-290P 4ignes by Cboal.Fire Dept-16 UST Regulatory Corripllance Unit;Ctepartlrlent of Piro uerrlces,P.O.E]cx 1.02 ;State Roar;Ston,MA 01776. llntarrnatirrigi I.-ire Code Irs',itute r?-+.92(revi�P�4(97) Fand Map/Parcel 070010001 -awn of Barnstable /AN f Health®epartmentHealthSystem K � l flFlSi/ // 1/.frT'l f2.sear. MaplParcel � 70010002 Tank Nbr 01 u o ,nW "Tag Nbro 00229 Installed 01/01/1975 Location a y� aaT Test Notification Dated 02/14/1997 Status r Date ` y ,rKw r Remoallotlflcation6date Tes 05/08/1997 RA "q xr�E mommAband � � Ae1YtOV81' 22v, 03/ /2006 Mar lance, 41 y Fu`e1 Stored Fuel StoragWRea;'&' H K r s Capacity Construction LeakDetecfion c CathodicDetect�on Stow e' ank Infos 001000 SS r a g �Additiorial Details/ PUTNAM HOUSE TEST 092096 r r a ✓ AYd Change 4 T7RE r ,. tYfAK@'fi�?plrt.t;6aue1 to tt,r.ai rtic vFp•o.••,�c� -!- `� 00.1 Forty!)ep5rtmeill;reteJns original application and issues duplicate as Permit, •{~� rl�% t/`i �/t/ LrL'P�l� ��{, r �' n J� lf"ehlul;,`�zeW?"t r� F APPLI CAT 10"M and PERMIT tFee: -� — `c�r sicra P tanF. ernova!and transpo,+M:on to a,Yprnved tai�'�disposal yaid in acrGrdanCe with the wrovisic:,,s ui Pvi<C.i_.Cha i r 'i 5, L don 3SA, r27 GK4R 9.00, appilcazion is hereby Liqa Rockwell. j ~'sine ioas� rin+' Oak Sarihr4 Farm -- x ar.: Nr ar i ;p. p r - ----- t,:ra di.pfwaiy tur ue rta ` Address,-- po Box r U�fervil.7 e_, NfA 0_2655 --- __ - -- StrcOf Gly S!arc —�P— a a e e e I Conpanytdarr -12.nvirc�-S�fe C rr.� -_ !. o.arindfvldual B:_nrtet. a — rr � . r- ; r Address�+' ��.11 _��Etx31 EQA-�yz-� 14 Ju.i �3 an Ur.. rep � dregs-----.r.—..__.- ----- Sa.l.c"wic"If VIP si E1 e(if eppiyiny far perms:'. I Sigr iaiure(is applying I&perr:ilt) i ii r' C 34iif t; iher„v ----- �. .0 lhCi Tcrflftd iQ LF'.4 - Beal Addra,rc to atY Tank Cepgclty(flailcn ?f '"�� _ ,,.bstance t.2vt 5tvred _--_-_ -- - Ta,;};E�imsrsions(diamzmr X iength) Re narks. _ ITncie. i eL ot_,:�ti Tan'. 1 060 y, 7ftm aC ..0 nsp ping wastes-_E n viz 0--a l f e C,c_.r P• -_ St6,p Lic.H i��#3 2 9 Huza.rdous was~_rnaiV Est# M c ry h 5 y-� -- E.F'.A. - - ICY�C 3 G C U J 1 i`;' vixt_ urtter, -i-nr Ta+k;ci"d#i CQ2 I f pproved-ank it;ppsai y — -- - — -_ -- - i Typa V Ice+t gas �.._. Tank ya;d address _4 _St r.�? t Ci(yorTaNn FLDIJft i 1 Data et Issue March�22 I - .-- ---- -- Date cif expiration I_)i f s ate ap:roval number: _2-0 G 6100 ry 2 2 2 �Dig Safe Trull Frae Tel.I urnbor 800-32 �+frr,� 15ignatuco Title of Officer granting parrr:it _ erg �!`z' �'?"�. c' /este r re movaf(s),'Consumptive Use' f-,e?I ctl tanks a xetnfpted sand Form Fir-o DOR�Igrled Icy lLocarl *ire Npt,to UST 9esuia'ury Corriplarice Unk,Cepattrr�ent of Fire 38tvR.,es,P.O.Sox 1�?..i,ti§at3 Roadr',Siow,.PAA 0177F,. . 'frrtsrn,+ion�f i=iry Cate!nstitut� . r w N x �0 Town of Barnstable Find Map7P rce[, 070010001 , a� Wealth Department Health System ` - ' s dd " ," 3���i FTa k Nbce 0T g bra 00232 � _ Installed 01/01/1980 Loc Lion ° Test Notffi`cataon D to 02/14/1997€, Status F Date Removal Notification©ateI Testy 4V. 97 05/08/19 � y andon- Uzi 3 Removal 03/22/2006 '�' � WOO fi FuelStorer! D �Fuel�Storage Reason i^ Capacity f Construction Leak DetectionCathodc DetectionIn Storage Tank Info 001000 SS AddItional Details CHILDREN S BARN TEST 092096 n r r xTO x dd s Change, .: a �r ;s a COMMONWEALTH OF MASSACH USETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO v SOUTHEAST REGIONAL OFFICE l 20 RIVERSIDE DRIVE, LAKEVILLE, MA 02347 508-946- MITT ROMNEY Governor STEPHEN R.PRITCHAR.D Secretary KERRY HEALEY Lieutenant Governor ROBERT W.GOLLEDGE,Jr. Commissioner URGENT LEGAL MATTER:PROMPT ACTION NECESSARY- June 26,2006 Scudder&Taylor Oil Company- RE: BARNSTABLE-BWSC ` . 55 Bodick Road 20 Scallop Path,Osterville t Hyannis,Massachusetts 02601 RTN#4-19870 "" s w+� NOTICE OF RESPONSIBILITY 4 M.G.L.c 21E,310 CMR 40.0000 _ ATIENTION:T m Walsh i On June 21,2006 at 10:00 am the Department of Environmental Protection("MassDEP")received oral notification of a release and/or threat of release-of oil and/or hazardous material at the above referenced ro which requires one or more re `property perty spouse-actions. It was reported an url�iown amount#2 fuel oil released into the basement/crawlspace from 2-330 gallon storage tanks. The Massachusetts Oil and Hazardous Material Release Prevention and Response Act, M.G.L. c.21E, and the Massachusetts Contingency Plan (the "MCP"), 310 CMR 40.0000,require the performance of response actions to prevent harm to health, safety,public welfare and the environment which may result from this release and/or threat of release and govern the conduct of such actions. The purpose of this notice is to inform you of your legal responsibilities under State law for assessing and/or remediating the release at this property. For purposes of this Notice of Responsibility, the terms and phrases used herein shall have the meaning ascribed to.such terms and phrases by the MCP unless the context clearly indicates otherwise. MassDEP has reason to believe that the release and/or threat of release which has been reported is or may be a disposal site as defined by the M.C.P. MassDEP also has reason to believe that you(as used in this letter, you" refers to Scudder &.Taylor Oil Company) are a Potentially Responsible,Party (a•"PRP") with liability under M.G.L. c.21E §5, for response action costs. This liability is "strict",meaning that it is not based-on fault, but solely on your status as owner, operator, generator, transporter, disposer or other person specified in M.G.L. c.21E §5. This liability is also "joint and several", meaning that you may be liable for all response action costs incurred at a disposal site sp osa sp s regardless of the existence of any other liable parties. This information is available in alternate format.Call Donald M.Gomes,ADA Coordinator at 617-556-1057.TDD Service-1-800-298-2207. DEP on the World Wide Web: http://www.mass.gov/dep Z� Printed on Recycled Paper d ' 2 MassDEP encourages parties with liabilities under M.G.L. c:21E to take prompt and appropriate actions in response to releases and threats of release of oil and/or,hazardous materials. By taking prompt action, you may significantly lower your assessment and cleanup costs and/or avoid liability for costs incurred by MassDEP in taking such actions. You may also avoid the imposition of, the amount of or reduce certain permit and/or annual compliance assurance fees payable under 310 CMR 4.00. Please refer to M.G.L. c.21E for a complete description of potential liability. For your convenience, a summary of liability under M.G.L. c.21E is attached to this notice. You should be aware that you may have claims against third parties for damages, including claims for contribution or reimbursement for the costs of cleanup. Such claims do not exist indefinitely but are governed by laws which establish the time allowed for bringing litigation. MassDEP encourages you to take any action necessary to protect any such claims you may have against third parties. At the time of oral notification to MassDEP, the following response actions were approved as an Immediate Response Action(IRA): • Assessment activities to determine if fuel oil migrated under the concrete floor. • Ventilation of basement/crawl space. • All Remediation Waste must be properly stored/handled and disposed of within 120 days from the date of generation per 310 CMR 40.0030. ACTIONS REQUIRED Additional submittals are necessary with regard to this notification including,but not limited to,the filing of a written IRA Plan, IRA Completion Statement and/or a Response Action Outcome (RAO) statement. The MCP requires that,a fee.of$1,200 be submitted to MassDEP when an RAO statement - -is.filed greater than 120 days-from the date of initial notification. Specific approval is required from assDEP for the implementation of all IRAs pursuant to'310 CMR 40.0420 and 310 CMR 40.0443, respectively. Assessment activities, the construction of a fence and/or the posting of signs are actions that are exempt from this approval requirement. In addition to oral notification, 310 CMR 40.0333 requires that a completed Release Notification Form(BWSC-103,•attached),be'submitted to MassDEP within sixty(60)calendar days of June 21,2006.. You must employ or engage a Licensed Site Professional (LSP) to manage, supervise or actually perform the necessary response actions at this site. You may obtain a list of the names and addresses of these licensed professionals from the Board of Registration of Hazardous Waste Site Cleanup Professionals by calling(617)556-1145 or visiting http://www.state.ma.us/lsp. Unless otherwise provided by MassDEP, potentially, responsible parties ("PRP's") have one year from the initial date of notification to MassDEP of a release or threat of a release, pursuant to 310 CMR ' 40.0300, or from the date MassDEP issues a Notice of Responsibility,whichever occurs earlier,to file with MassDEP one of the following submittals: (1) a completed Tier Classification. Submittal; (2) an'RAO Statement or, if applicable, (3) a Downgradient Property Status. The deadline for either of the first two submittals for this disposal site ds June 21, 2007. If required by the MCP, a completed Tier I Permit Application must also accompany a Tier Classification Submittal. This site shall not be deemed to have had all the necessary and required response actions taken unless and until all substantial hazards presented by the release and/or threat of release have been eliminated and a level of No Significant Risk exists or has been achieved in compliance with M.G.L. c.21E and the MCP. If you have any questions relative to this Notice,please contact Michael Whiteside at the letterhead address or at (508) 946-2704. All future,communications regarding this release must reference the following Release Tracking Number: 4-19870. Very truly yours, Richard F.Packard,Chief Emergency Response/Release Notification Section P/MCW/ Attachments: Release Notification`Form;BWSC-103 and Instructions Summary of Liability under M.G.L.c.21E MassDEP's guide to hiring a Licensed Site Professional. cc: Board of Health Board of Selectmen Fire Dept r CIF COMMONWEALTH OF MASSACHUSETTS- EXECUTIVE OFFICE OF ENVIRONMENTAL AF ` DEPARTMENT OF ENVIRONMENTAL PRO SOUTHEAST REGIONAL OFFICE MPY 20 RIVERSIDE DRIVE, LAKEVILLE, MA 02347 508-946- 2700 MITT ROMNEY Governor STEPHEN R.PRITCHARD Secretary KERRY HEALEY Lieutenant Governor ROBERT W.GOLLEDGE,Jr. Commissioner URGENT LEGAL MATTER:PROMPT ACTION NECESSARY June 26,2006 Rachel Mellon RE: BARNSTABLE_BWSC ' P.O.Box D 20 Scallop Path,Ostervillei Osterville,Massachusetts 02655 RTN#4-19870' c/o Lisa Rockwell _ NOTICE OF RESPONSIBILITY ` k{.� M.G.L. c. 21E,310 CMR 40.0000311 t ATTENTION: LisaLisa ockwell� � r On June 2.1,2006.at 10:00 am the Department of Environmental Protection "MassDEP ":.. ( ).received oral notification of a release and/or threat of release of oil-and/or`hazardous material at the above referenced property which requires one or more response actions, It was reported that an unknown amount#2 fuel oil released into the basement/crawlspace from 2-330 gallon storage tanks. The Massachusetts Oil and Hazardous Material Release Prevention and Response Act, M.G.L. c.21E, and the Massachusetts Contingency Plan (the "MCP"), 310 CMR 40.0000,require the performance of response actions to prevent harm to health, safety,public welfare and the environment which may result from this release and/or threat of release and govern the conduct of such actions. The purpose of this notice is to inform you of your legal responsibilities under State law for assessing and/or remediating the release at this property. For purposes of this Notice of Responsibility, the terms and phrases used herein shall have . the meaning ascribed to such terms and phrases by the MCP unless the context clearly indicates otherwise. MassDEP has reason to believe that the release and/or threat of release which has been reported is or may be a disposal site as defined by the M.C.P. MassDEP also has reason to believe that you(as used in this letter, "you"refers to Rachel Mellon) are a Potentially Responsible Party(a"PRP")with liability under M.G.L. c.21E §5, for response action costs. This liability is "strict",meaning that it is not based on fault, but solely on your status as owner, operator, generator, transporter, disposer or other person specified in M.G.L. c.21E §5. This liability is also "joint and several",meaning that you may be liable for all response action costs incurred at a disposal.site regardless of the existence of any other liable parties. This information is available in alternate format.Call Donald M.Gomes,ADA Coordinator.at 617-556-1057.TDD Service-1-800-298-2207. DEP on the World Wide Web: http://www.mass.gov/dep Zia Printed on Recycled Paper I 2 MassDEP encourages parties with liabilities under M.G.L. c.21E to take prompt and appropriate actions in response to releases and threats of release of oil and/or hazardous materials.By taking.prompt action, you may significantly lower your assessment and cleanup costs and/or avoid liability for costs incurred by MassDEP in taking such actions. You may also avoid the imposition of, the amount of or reduce certain permit and/or annual compliance assurance fees payable under 310 CMR 4.00. Please refer to M.G.L. c.21E for a complete description of potential liability. For your-convenience, a summary of liability under M.G.L.c.21E is attached to this notice. You should be aware that you may have claims against third parties for damages, including claims for contribution or reimbursement for the costs of cleanup. Such claims do not exist indefinitely but are governed by laws which establish the time allowed for bringing litigation. MassDEP encourages you to take any action necessary to protect any such claims you may have against third parties. At the time of oral notification to MassDEP, the following response actions were approved as an Immediate Response Action(IRA): • Assessment activities to determine if fuel oil migrated under the concrete floor. • Ventilation of basement/crawl space. • All Remediation Waste must be properly stored/handled and disposed of within 120 days from the date of generation per 310 CMR 40.0030. ACTIONS REQUIRED Additional submittals are necessary with regard to this notification including,but not limited to,the filing of a written IRA Plan, IRA Completion Statement and/or a Response Action Outcome (RAO) statement. The MCP requires that a fee of$1,200 be submitted to MassDEP when an RAO statement is-filed greater than 120 days from the.date of initial notification. Specific approval is"required from MassDEP for the implementation of all IRAs pursuant to 310 CMR 40.0420 and 310 CMR 40.0443; respectively. Assessment activities;the construction of a fence and/or the posting of signs are actions that are exempt from this approval requirement. In addition to oral notification, 310 CMR 40.0333 requires that a completed Release Notification Form 03WSC-103,attached)be submitted to MassDEP within sixty(60)calendar days of June 21,2006. You must employ or engage a Licensed Site Professional (LSP) to manage, supervise or actually perform the necessary response actions at this site. You may obtain a list of the names and addresses of these licensed professionals from the Board of Registration•of Hazardous Waste Site Cleanup Professionals by calling(617)556-1145 or visiting http://www.state.ma.us/lsp. Unless otherwise provided by MassDEP, potentially responsible parties ("PRP's") have one year from the initial date of notification to MassDEP of a release or threat of a release, pursuant to 310 CMR 40.0300, or from the date MassDEP issues a Notice of Responsibility,whichever occurs earlier,to file with MassDEP one of the following submittals: (1) a completed Tier Classification Submittal; (2) an RAO Statement or, if applicable, (3) a Downgradient Property Status. The deadline for either of the first two submittals for this disposal.site is June 21, 2007. If required by the MCP, a completed Tier I Permit Application must also accompany a Tier Classification Submittal. f 3 This site shall not be deemed to have had all the necessary and required response actions taken unless and until all substantial hazards presented by the release and/or threat of release have been eliminated and a level of No Significant Risk exists or has been achieved in compliance with M.G.L. c.21E and the MCP. P If you have any questions relative to this Notice,please contact Michael Whiteside at the letterhead address or at (508) 946-2704. All future communications regarding this release must reference the following Release Tracking Number:4-19870. Very truly yours, Richard F.Packard,Chief Emergency Response/Release Notification Section P/MCW/ Attachments: Release Notification Form;BWSC-103 and Instructions Summary of Liability under M.G.L.c.21E MassDEP's guide to hiring a Licensed Site Professional. cc: Board of Health' Board of Selectmen r Fire Dept `. Time,`C s , Commonwealth of Massachusetts ■ 100191909 J " Asbestos Notification Form ANF-001 Decal Number Important:When filling out A. Asbestos Abatement Description forms on the computer,use 1. a. Is this facility fee exempt-city,town, district, municipal housing authority, owner-occupied only the tab key residence of four units or less?[]Yes ❑No to move your cursor-do not b. Provide blanket decal number if applicable:use the return Blanket Decal Number key. 2. Facility Location: MELLON 20 SCALLOP PATH a.Name of Facility b.Street Address MA 02655 c.City/Town ,q �eA� d.State e.Zip Code f.Telephone Number INSTRUCTIONS 3. Worksite Location: 1.All sections of this ELECTRICAL ROOM form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room completed in order to comply with 4. Is the facility occupied? ❑✓ Yes ❑No DEP notification requirements of 310 CMR 7.15 5. Asbestos Contractor: and the Division of occupational INEW ENGLAND SURFACE MAINTENANCE 850 WASHINGTON STREET Safety(DOS) a.Name b.Address notification WEYMOUTH 02189 7813372117 requirements of 453 CMR 6.12 c.City/Town d.Zip Code e.Telephone Number AC000196 f.DOS License Number g. Contract Type: ❑Written ❑Verbal h.Facility Contact Person i.Contact Person's Title 6 JOSE VILLALTA I JAS061825 a.Name of On-Site Supervisor/Foreman b.Supervisor/Foreman DOS Certification Number BOWEN AM035129 7' a.Name of Project Monitor b.Project Monitor DOS Certification Number FLI ENVIRONMENTAL AA000144 8' a.Name of Asbestos Analytical Lab b.Asbestos Analytical Lab DOS Certification Number 01/24/2014 01/24/2014 9` a.Project Start Date mm/dd/ b.End Date mm/dd/ �0 8-4 �N c.Work hours Mon-Fri. d.Work hours Sat-Sun. =o 10. a. What type of project is this? �o ❑ Demolition ❑ Renovation ❑✓ Repair ❑Other, please specify: b.Describe 11. a. Check abatement procedures: ° ❑Glove bag El Encapsulation o ❑ Enclosure ❑ Disposal only �LL ❑Cleanup ❑Other, specify: � ❑✓ Full containment b.Describe Z �Q 12. Is the job being conducted: ❑✓ Indoors? ❑Outdoors? , anf001ap.doc•10/02 Asbestos Notification Form•Page.1 of 3 i Commonwealth of Massachusetts 100191909 Asbestos Notification Form ANF-001 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or enca sulated: 0 1 1650 a.Total pipes or ducts(linear ft) o. I otal other surfaces square c.Boiler,breaching,duct,tank d.Insulating cement surface coatings Lin.ft. Sq.ft. Lin.ft. Sq.ft. e.Corrugated or layered paper f.Trowel/Sprayer coatings pipe insulation Lin.ft. S ft. Lin.ft. Sq.ft. g.Spray-on fireproofing h.Transite board,wall board 650 Lin S� Lin S� i.Cloths,woven fabrics Lin.ft. Sq.ft. 1.Other,please specify: Lin.ft. So.ft. k.Thermal,solid core pipe insulation Lin Sq.ft. I.Specify 14. Describe the decontamination system(s)to be used: AS REQUIRED _. 15. Describe the containerization/disposal methods to comply with 310 CMR7.1. and 453 CMR 6.14(2) (g): AS REQUIRED 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: a.Name of DEP Official b.Title c.Date mm/dd/y of Authorization d.DEP Waiver# e.Name of DOS Official f.DOS Official Title �N g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver# �0 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A=F apply to this project? ❑Yes ✓ No B. Facility Description �N =0 RESIDENCE 1. Current or prior use of facility: �o 2. Is the facility owner-occupied residential with 4 units or less? ❑✓ Yes ❑ No SAME 3' a.Facility Owner Name b.Address _o o c.City/Town d.Zip Code e.Telephone Number area code and extension LL 4' a.Name of Facility Owner's On-Site Manager b.On-Site Manager Address �Q c.City/Town dd.Zip Code e.Telephone Number(area code and extension) anf001 ap.doc•10/02 Asbestos Notification Form•Page 2 of 3 Commonwealth of Massachusetts L - 100191909 Asbestos Notification Form ANF-001 Decal Number B. Facility Description (cont.) 5' a.Name of General Contractor b.Address i c.Ci /Town d.ZipCode e.Telephone Number area code and extension f.Contractor's Worker's Comp.Insurer g.Policy Number h.Exp.Date mm/dd 6. What is the size of this facility? a.Square Feet b.Number of floors C. Asbestos Transportation and"Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): NESM, LLP Note:Transfer a.Name of Transporter b.Address Stations must comply with the c.Citylrown d.Zip Code e.Telephone Number Solid Waste Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19.000 RED TECHNOLOGIES a.Name of Transporter b.Address c.Ci /Town d.Zip Code e.Telephone Number 3. a.Refuse Transfer Station and Owner b.Address c.CitVITown d.Zip Code e.Telephone Number 4. IMINERVA ENTERPRISES INC a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name 9000 MINERVA ROAD I IWAYNESBURG c.Final Dis osal Site Address d.City/Town OH 144688 i_M e.State f.Zip Code g.Telephone Number 0 D. Certification N The undersigned hereby states, under the JJIM DOYLE 9�° penalties of perjury,that he/she has read the P 1 rY, a.Name b.Authorized Si nature �o Commonwealth of Massachusetts regulations 1/13/2014 for the Removal, Containment or c.Position/Title d.Date mm/dd/ _ Encapsulation of Asbestos,453 CMR 6.00 and NESM, LLP 310 CMR 7.15, and that the information contained in this notification is true and correct e.Telephone Number f.Representing to the best of his/her knowledge and belief. o .Address W�LL h.City/Town i.Zip Code �z anf001ap.doc•10/02 Asbestos Notification Form•Page 3 of 3 t 4 Town of Barnstable w tHE t Regulatory Services v�� •1,a ' : Thomas F.Geiler,Director Public Health Division snxrisTn t.�. v = Thomas McKean,Director v x HtAss 200 Main Street, Hyannis,MA 02601 FD NIP'l Phone: 508-862-4644 Email: health(a,town.barnstable.ma.us Fax: 508-790-6304 Office Hours: M-F 8:00—4:30 February 15,2006 Ms. Rachel Mellon /Je) 0tD r00 20 Scallop Path / Osterville,MA 02655 Mir Dear Ms. Mellon: Recently a letter has been released to homeowners and commercial business owners regarding the removal of Underground Storage Tanks (UST). When removals, abandonment, and testing of the tanks have occurred, our electronic files are updated. We have found that many files have not been correctly updated and/or the proper notification was not received by our Department. Our records indicate that you have been contacted regarding a 1,000 gallon Underground Storage Tank of Diesel fuel located at 20 Scallop Path,Osterville,MA. This tank is listed on Parcel 010- 002 on Assessor's Map 070 and is registered with the Health Department as tank tag#229. We do not have record showing the tank was removed. The tank is constructed of Single Walled Steel and according to the Board of Health Code,Fuel and Chemical Storage Tanks Chapter 326- 8; it does not satisfy the construction requirements of Subsection D of that section and shall be removed since the tank is not located in a critical zone of contribution to our public drinking supply and is over 30 years old from the installation date being 1975. It is necessary for us to update our records at this time and in order to do so; we will need the proper documentation of the removal. If we do not hear from you or receive information regarding this tank, corrective action shall be taken. Should you have any questions,comments,of if you need further information, guidance or assistance,please do not hesitate to contact the Public Health Division. Sincerely, Alisha L. Parker- Hazardous to als Specialist omA. cKean,RS, CHO Director of Public Health f frown O#Barn h F� tl Map/Parcel 070010002 s� �� � � � � �Healtfh©epartme t�ealttrSystem� Rip 70010002 Map/ParCei.l 0 / Y a k ' Tank Nbr Al 01Tag Nb . 00229 A lns a 01/01/1975= vocation Bt �.,,., s Test Noti#tcaticinDate 02/14/1997 SSW bate " Remo�valNotificatrorl}ateIT 94f65/�966- jests 1a 1 h =:/ /�//1. �'l/i K N! „ 00 h � RMea riaavael' p , Mgll� v, t j u 1 Sretl D Storage Reasoner H ru UW.F ea Aefectton C'athod C # ec ion Storage Tank Info= 001000 .SS N � '" AtldI IonallDetails PUTNAM ROME TEST 092096 / _W P 1 a i li CENTERVILLE-OSTERVILLE-MARSTONS MILLS FIRE DISTRICT t 9 675 ROUTE 28 I CENTERVILLE, MA 02632 (508)790-2380/FAX#(508)790••2385 (f OIUHAZARDOUS MATERIAL RELEASE FORM �} F.A.# '_ LOCATION: ADDRESS OF RELEASE: PA 0I If DATE OF RELEASE: PRODUCT RELEASED: 1 ESTIMATED QUANTITY' """��� CORRECTIVE ACTION TAKEN BY RESPONSIBLE PARTY: I NOTIFICATIONS: FIRE DEPARTMENT: YES( ) NO( ) DATE: TIME: NATIONAL RESPONSE CEATER YES( } Nth{( ATE: TIME: DEPT. OF ENVIRONMENTAL PROTECTION Y ( } NO( ) DATE: T.lME: 1 OIL SPILL COORDINATOR: YES( ) NO( } x DATE: l/�l�'�� mW"4 o caner j TOWN BOARD OF HEALTH: YES(R)X} NO( ) DATE: ;:i4j4,W TIME: .... TOWN HARBORMASTER: ; ' YES( } NO( } DATE:____TIME. �TIME:� i OTHER AGENCIES: T� j COMMENTS:_AAo Y... T;pp R-1-- 9R i i!e i e!c£ic ilF�e� eirei=csu�� x�o" "' E�J, REPORTED BY Izi ' J DATE: P4acee�`ly,`fit U 1� v II J WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH C-O-fAM FORM#58 l t a t ; MM DD yyyy Delete NFIRS _ 101920 U 06 19 2006 U 1 06-000167" 000 ❑Change Basic 1 FDID .* State* Incident Date * Station Incident Number * Exposure * ❑No Activity Check this box to Indicate that the address for this incident is provided on the Wildland Fire Census Tract I gLocation* ❑Module In Section B "Alternative Location Specification". Use only for Wildland fires. ®street address 20 "J SCALLOP PA U U ❑Intersection Number/Milepost Prefix Street or Highway Street Type Suffix ❑In front of L� ❑Rear of J OSTERVILLE I IMA 1 102655 �-1 � ❑Adjacent to Apt./Suite/Room City State Zip Code l l []DirectionsCross street or directions, as applicable Midnight is 000o Shift & Alarms C Incident .Type # E1 Date & .Times E;2 413 JOil or other combustible liquidl check boxes if Month Day Year Hr Min Sec Local Option dates are the Incident Type same as Alarm ALARM always required 14 I COM2 3 Aid Given or Received* Date. Alarm .* 06 19 .2006 112:31:03 l shift or Alarms District DPlatoon ARRIVAL required, unless canceled or did not arrive 1 ❑Mutual aid received ❑ Arrival 1 061 191 u 112:5 0:48 I E 3 ,2 ❑Automatic aid recv. Their FDID Their State CONTROLLED Optional" , Except for wildland fires Special .Studies 3 ❑Mutual aid given I "I I 4 ❑Automatic aid given l l ❑Controlled I I I Local Option 5 ❑other aid given Their LAST UNIT CLEARED, required except for wildland fires I I U N ❑None Incident Number Last Unit 06 19 2006 4: Special Special 151:32 S lD# t Study ❑ Cleared l F Actions Taken* Gl Resources# G2:Estimated Dollar :Mosses & Values ❑ Check this box and skip this .LOSSES: Required for all fires if known. Optional section if an Apparatus or 182 lNotify other agencies. Personnel form is used. for non fires. None $I ' ' � ' ❑ Apparatus Personnel Property 000 II 000 Primary Action Taken (1) gq lRefer -to proper l Suppression I Contents :$u 000 1 000 ❑ Additional Action Taken (2) EMS U U PRE-INCIDENT VALUE: Optional 86 IInvesti ate Other l 0003 Pro I 00051 Property .$U �. � 0 ❑ 4 � 000 u 000 Additional Action Taken (3) ❑ Check box if resource counts include aid received resources. Contents ,,�'L ,-. QQJ , 000 ❑ Completed Modules :Hl,*Casualties❑None 'H3 Hazardous Materials Release = Mixed Use Property ❑Fire-2 Deaths :Injuries N []None NN Not Mixed 1 0 Assembly use ❑Structure=3 Fire 1 I I 1 Natural Gas: leak, nn.avanation or MazMat actions �20 (_J �_J Education use Service Medical use ❑Civil .Fire Cas.-4 2 ❑Propane gas: 121 lb. tank 4aa in hose aBQ grill) 33 ❑'Fire Serv. Cas.-5 [ � '3 []Gasoline: vehicle feel tank or portable container 40 Residential ,use Civilian ❑EMS-6 4 ❑Kerosene: fuel burning equipment or portable storage 51 Row of .stores Detector 53 Enclosed mall ❑HazMat-7 Required for confined Fires. 5 ❑Diesel 'fuel/fuel oil:,,ehicle fuel tank or portable 58 Bus. .& Residential ❑ Wildland Fire-8 6 ❑Household solvents: home/office spill, cleanup only 59 Office use 1❑Detector alerted occupants OApparatus-9 7 ❑Motor oil: from-engine or portable container 60 Industrial use oPersonnel-.10 2❑Detector did not.alert them g ❑Paint• from paint cans totaling< 55 gallons -63 65 Military use Farm❑Arson-11 u❑Unknown 0 []other: special H—Hat actions required or spill> 55ga1., 00 Other mixed use plea late the HazMat form J Property Use# Structures 341❑Clinic,clinic type infirmary .539 ❑Household goods,sales,.repairs 342❑Doctor/dentist office 579 ❑Motor vehicle/boat sales/repair .131 ❑Church, .place of worship 3 61❑Prison or jail, not -juvenile 57.1 ❑ Gas or service station 161 ❑Restaurant or cafeteria 41971-or.2-family dwelling 599 ❑ Business office 162 ❑Bar/Tavern or nightclub 42 9❑Multi-family dwelling 615 [:)Electric generating plant 21 3 ❑Elementary school or kindergarten .43 9❑Rooming/boarding house 629 ❑Laboratory/science .lab 215 ❑High.school or junior high .449❑Commercial.hotel or motel 700 ❑Manufacturing plant 24.1 ❑College, adult education 459[:)Residential, board and care 819 ❑Livestock/poultry storage(barn) 311 ❑Care facility-for the aged .464❑Dormitory/barracks 882 ❑Non-residential parking garage 331 ❑Hospital 51 9❑Food and beverage sales 891 ❑warehouse Outside 936 ❑Vacant lot 981 ❑ Construction site 124 ❑Playground or park 938 ❑Graded/care for plot of .land 984 ❑ Industrial plant yard 655 ❑Crops or orchard 946 ❑Lake, .river, stream 669 ❑Forest (timberland) 951 ❑Railroad right of way Lookup and enter a Property Use code only if g y you have NOT checked a Property Use box: 807 ❑Outdoor storage area 960 ❑Other street Property Use 1419 919 ❑Dump or sanitary landfill 961 ❑Highway/divided highway 931 ❑Open land or field 962 ❑ 11 or 2 family dwelling lResidential street/driveway NFIRS-1 Revision 03 11 99 COMM Fire District 01920 06/19/2006 06-0001674 MM DD YYYY 1 01920 U 1 61 1 191 1 2006 U ( 06-0001674 1 000 Complete FDID State Incident Date Station Incident Number Exposure Narrative 'Narrative: Caller Name : LISA ROCKWELL Caller Phone : 420-1788 Caller Address : SAA OIC : MACNEELEY lmotte 2006/06/19 12:50:48 - 303 AT EVENT MANNING IS 3 lmotte 2006/06/19 12:53:15 - 321 AT EVENT MANNING IS 1 lmotte 2006/06/19 13:17:45 - 329 AT EVENT MANNING IS 1 lmotte 2006/06/19 12:41:28 PAST OIL SPILL, ALREADY CLEANED UP BY SCUDDER AND TAYLOR, POSS MORE THAN 10 GALS' IN CRAWLSPACE lmotte 2006/06/19 12:57 :32 321-ENG AVAILABLE, REQ FIRE PREVENTION lmotte 2006/06/19 13:31:06 321-REQ BOB lmotte 2006/06/19 13:34 :44 TO BOH-WILL BE ENR, 15-20 MIN ETA lmotte ; 2006/06/19 14:51:30 BOB HAS BEEN HERE, TURNED BACK OVER TO HOMEOWNER, CLR 06/19/2006 19: 12:42 jtavares 321, 303 to the above incident, upon our arrival we determined that there was in fact a prior reportable home fuel oil spill in the basement that has since been cleaned up. Fire Prevention and Board of Health was requested and FPO MacNeely to follow up and complete the report. David Stanton and Alisha Parker Health Inspectors from TOB on site to evaluate spill. Based on information received at the location from OH Security (Bob Police 508-428-1695) and property owner representative (Lisa Rockwell 508-420-1708) the following is the most likely scenario. Based on security visits spill occurred sometime between midnight and 6am on June 17th. Strong fuel oil odor noticed by security at 6am and they subsequently found a leaking fitting on tanks in basement crawl space. Service contractor immediately notified (Scudder Taylor) . Security used speedy dry material to help contain fuel until leak stopped by Scudder Taylor at approximately 09:30hrs. Scudder Taylor spent 3 to 4 hours cleaning up spilled product and stated that it was not a reportable quantity that was spilled (>10 gallons) Lisa Rockwell reported in person to Centerville FD that even today 6/19 a strong fuel oil odor remains in the house. She is concerned about odor and wanted to know what we could do to help. BOH evaluated area of spill approximately 95% had been cleaned up. A small area of oil and speedy dry remained under the (2) 330 gallon fuel tanks. There was some concern about hou much oil may have gone below the concrete floor through cracks in floors especially around a plumbing pipe in the floor. Area check by David Stanton floor appeared in good condition, he does not believe that much of the oil made it through the floor. Difficult to determine how much oil spilled but likely is was a reportable quantity. BOB to contact Scudder Taylor about fuel spill and disposal of product removed from site. Recommended to Lisa Rockwell to work with Scudder Taylor and specialized clean-up company on getting odors under control and final clean-up of remaining spill. COMM Fire District 01920 06/19/2006 06-0001674 MM DD YYYY 1 01920 U 1 61 1 191 1 2006 1 2 06-0001674 000 complete FDID State Incident Date Station Incident Number Narrative -* * Exposure 'Narrative: Fitting has been repaired on tank. 329 cleared scene Met with David Stanton Barnstable BOH and Richard Packard from DEP back out at 20 Scallop Path. DEP was contacted by Lisa Rockwell at the request of the property owner (Mellon) . Richard Packard viewed site and spoke with property rep, BOH, and myself. Actions by Scudder Taylor are a fineable offense. Fuel oil odor is less than before but still does exist in home. DEP will follow-up with Scudder Taylor on proper procedures for spill reporting. In addition, he recommends further evaluation be done to confirm that oil, did not spread beyond concrete. 329 cleared. 07/11/2006 14 :15:50 mmacneely COMM Fire District 01920 06/19/2006 06-0001674 R1 Person/Entity Involved Local Option Business name (if applicable) U Area Code Phone Number j ChecY. This Box if I I MI Last Name LJ Mr.,Ms., Mrs. First Name Suffix same address as incident location. Then skio the three duplicate address Number prefix Street or Highway Street Type Suffix lines. Post Office Box Apt./Suite/Room City U l. 1-UU State Zip Code More people involved? Check this box and attach Supplemental Forms (NFIRS-1S) as necessary R2 owner Same as person involved? I I Then check this box and skip The rest of this section. u Local Option Business name (if.Applicable) Area Code Phone Number UU I I U I I u ❑ ChecY. this box if Mr.,Ms., Mrs. First Name MI Last Name Suffix same address as I I U I I U U incident location. Then skip the three duplicate address Number Prefix Street or Highway Street Type Suffix lines. I I ' 1 Post Office Box Apt./SuiUte/Room City State Zip Code .Remarks Local Option Caller Name : LISA ROCKWELL Caller Phone 420-1788 Caller Address : SAA OIC : MACNEELEY lmotte 2006/06/19 12:50:48 - 303 AT EVENT MANNING IS 3 lmotte 2006/06/19 12:53:15 - 321 AT EVENT MANNING IS 1 lmotte 2006/06/.19 13:17:45 - 329 AT EVENT MANNING IS 1 lmotte 2006/06/19 12:41:28 PAST OIL SPILL, ALREADY CLEANED UP BY SCUDDER AND TAYLOR, POSS MORE THAN 10 GALS IN CRAWLSPACE lmotte 2006/06/19 12:57:32 321-ENG AVAILABLE, REQ FIRE PREVENTION lmotte 2006/06/19 13:31:06 321-REQ BOH lmotte 2006/06/19 13:34:44 TO BOH-WILL BE ENR, 15-20 MIN ETA lmotte ; 2006/06/19 14 :51:30 BOH HAS BEEN HERE, TURNED BACK OVER TO HOMEOWNER, CLR Z :Authorization 18480 I I TAVARES, JOHN M. A ELT I 1321 61 1911 2006 Officer in charge ID Signature Position or rank Assignment Month Day Year Check 8350 MACNEE MART O.In FIRE/INSP U I� I 2006 Box if same Po on or rank Assig ent Month Day Year as Officer Member making report Sign ure in charge. 1 COMM Fire District 01920 06/19/2006 06-0001674 From: 07/22/2021 09.01 #861 P.001/001 ENVIROTECHLABORATORIES,INC. MA CERT.NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,IVA 01563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name: Jimmies Ice Cream Location Address: 4075 Falmouth Rd Cotuit,MA Osterville/Cotuit,MA 02635 Lab Number: DW-213337 Collected By: J.Guinta Date Received: 07/19/21 Sample Type: Frozen Dessert Well Specs: NA Ell ':^ ' �'•ri�,7.,„k� �' +,ct' �.'�a P 5,�.,�.�+ s,a,"✓,• RIM x�tx !Y� - •.�i�^ rr�*3si'K� "i-x Ana[vsis Requested Units Recommended Limits Analysis Result I H dhod Dare Analyzed Analyzed By Ice Cream Coliform /gram 50 >60 Pour Plate 07/1912021 SD @ 20:30 Standard Plate Count /gram 50,000 >50,000 Pour Plate 07/19/2021 SD Comments: Suggest retest. All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. No-parameters of frozen dessert tested are not within recommended limits. .7•y-a''x�.-'ns^r. .r �'3 i; �.a,.�„r.,+...�;. ,•. Y. v.... _.^ pip'yi`�t r .z" �.£. .,a�z�r��, ''.t-.wx?i- -_'. t"s �...taws � �a�t. ,� 4^�;, K s 3' �' kz..•x t� r 'o t x � '� w` 'xA,�. 7,�:..i 4+ Ys^ iz"i a. fc.a^" ,� s✓}' y�.a ty.,..a- „":£^ ._4'x $.�"cK ap '' , „�y tw ax.,S�x-.�Sxc'x 2 �. -.s�' -4� Analysis Requested Units Recommended Llmirs Analysis Result /�telhod Date Analyzed Analyzer[By Ice Cream Coliform /gram 50 >60 Pour Plate 07/19/2021 SD @ 20:30 Standard Plate Count /gram 50,000 >50,000 Pour Plate 07/1912021 SD Comments: All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. No-parameters of frozen dessert tested are not within recommended limits. Date 7/22/2021 Ronald J.Saari Laboratory Director BRL=Below Reportable Limits "See Attached Page 1 of 1 oCertification is not available for this analyte for potable water samples.. From: 07/22/2021 09:23 #863 P_001/001 ENVIROTECH LABORATORIES,INC. MA CERT.NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name: Katies Ice Cream Location Address: 568 Main St. 568 Main St Hyannis,MA Hyannis,MA 02601 Lab Number: DW-213315 Collected By: Katie's Ice Cream Date Received: 07/19/21 Sample Type: Frozen Desert Well Specs: NA NO f.r.� ., �.'�S.'L'�' z''� �'.^ai-r�:,.t�"xr , -.s yr'''' �sr,.. yea' A 1.�:� >;- ar n„,. E� ..—.c... {� ��es�r� v-f,'�R,..1%...k.�•_". wr»i'c-,.,.:.�_.. .�9i7..N�.X:<s.a=.... <,.-Ari<:.nw ..< .1.. ;. > �:Y-'F.:.. �T.... ..�i�.��?�,'^r^.'Nm✓....5... :t:.�. ..-.. Analysis Requested Units Recommended Lindis Analysis Result Method Date Analyzed Analyzed By Ice Cream Coliform /gram 50 <1 Pour.Plate 07/19/2021 SD @ 20:30 Standard Plate Count /gram 50,000 2,300 Pour Plate 07/19/2021 SD Comments: All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. Yes-Parameters of frozen dessert tested are within recommended limits. Date 7/22/2021 Ronald J.Saari Laboralory Director BRL=Below Reportable Limits 'See Attached Page 1 of 1 aCertification is not available for this analyte for potable water samples.. Massachusetts Department of Environmental Protection 100281383 _ I' �WP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form Project Revision rl Project Cancellation A. Asbestos Abatement Description 1.Facility Location: LLOYD 20 SCALLOP PATH Instructions 1.All a.Name of Facility b.Street Address sections of this form BARNSTABLE must be completed in MA 02655 0000000000 order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification x x requirements of 310 CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title Department of Labor Worksite Location: 1STAND 2ND FLOOR Standards(DLS) notification i.Building Name,Wing,Floor,Room,etc. requirements of 453 2. Is the facility occupied? r a.Yes r!b.No CMR 6.12 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owner-occupied residential property of four units or less)? r a.Yes r b.No MassDEP Use Only 4.Blanket Permit Project Approval,if applicable: Date Received Approval ID# 5.Non-Traditional Asbestos Abatement Work Practice Approval, 2.Submit Original if applicable: Approval ID# Form To: Commonwealth of Massachusetts 6.Asbestos Contractor: P.O.Box 4062 Boston,MA 02211 NEW ENGLAND SURFACE MAINTENANCE LLP 850 WASHINGTON ST a.Name b.Address WEYMOUTH MA 02189 7813372117 c.City/Town d.State e.Zip Code f.Telephone AC000196 h.Contract Type: r 1.Written r-2.Verbal g.DLS License# 7. JOSE VILLALTA AS061825 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# 8 RICHARD K BOWEN AM061044 a.Name of Project Monitor b.DLS Certification# 9 FLI ENVIRONMENTAL INC AA000144 a.Name of Asbestos Analytical Lab b.DLS Certification# 10. 3/12/2018 3/12/2018 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 8-4 N/A c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11.What type of project is this? r a.Demolition r, b.Renovation r c.Repair r d.Other-Please Specify: Revised: 11/13/2013 Page 1 of 4 Massachusetts Department of Environmental Protection 100281383 BWP AQ 04 (ANF-001) Asbestos Project Asbestos Notification Form # r Project Revision r Project Cancellation A.Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): r a.Glove Bag r b.Encapsulation rI c.Enclosure r d.Disposal Only r e.Cleanup r f.Full Containment r g.Other-Please Specify: 13.Job is being conducted: r a.Indoors r' b.Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 300 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct, c.Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation e.Transite Shingles 1.Lin.Ft 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f.Spray-On Fireproofing g.Transite Panels 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. h.Cloths,Woven Fabrics i.Other-Please Specify: 1.Lin.Ft. 2.Sq.Ft. j.Insulating Cement VERMICULITE 300 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15.Describe the decontamination system(s)to be used: AS REQUIRED 16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): AS REQUIRED 17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18.Do prevailing wage rates as per M.G.L.c. 149,§26,27 or 27A—F apply to this r a.Yes r.. b.No project? Revised: 11/13/2013 Page 2 of 4 Massachusetts Department of Environmental Protection - - i 100281383 BWP AQ 04 (ANF-001) � Asbestos Notification Form Asbestos Project# �y r, Project Revision �1 r Project Cancellation B. Facility Description 1.Current or prior use of facility: RESIDENCE 2.Is the facility owner-occupied residential with 4 units or less? ri a.Yes r_7 b.No 3 LLYOD 20 SCALLOP PATH a.Facility Owner Name b.Address OSTERVILLE MA 02655 0000000000 c.City/Town d.State e.Zip Code f.Telephone 4.X X a.Name of Facility Owner's On-Site Manager b.Address X MA 00000 000000000 c.City/Town d.State e.Zip Code f.Telephone 5 X X a.Name of General Contractor b.Address X MA 00000 0000000000 c.City/Town d.State e.Zip Code f.Telephone X g.Contractor's Worker's Compensation Insurer X 1/1/2019 h.Policy# i.Expiration Date(MM/DD/YYYY) 6.What is the size of this facility? 2000 2 a.Square Feet b.#of Floors C. Asbestos Transportation & Disposal 1.Transporter of asbestos-containing waste material from site of generation: r a.Directly to Landfill or r b.To Temporary Storage Location/Transfer Station NEW ENGLAND SURFACE MAINTENANCE,LLP 850 WASHINGTON STREET c.Name of Transporter d.Address Note:Temporary storage of Asbestos WEYMOUTH MA 02189 7813372117 containing waste e.City/Town f.State g.Zip Code h.Telephone material is only allowed at the place of business of a DLS 2,If a temporary storage location/transfer station is used,list name of transporter of asbestos containing licensed Asbestos l f waste material temporary storage location/transfer station to final disposal site: contractor or a transfer p ry g p station that is permitted by RED TECHNOLOGIES 10 NORTHWOOD DRIVE MassDEP and a.Name of Transporter b.Address operated in compliance with Solid BLOOMFIELD CT 06480 8603421022 Waste Regulations 310 CMR 19.000 c.City/Town d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 Massachusetts Department of Environmental Protection - - BWP AQ 04 (ANF-001) 100281383_ -__ - L771 Asbestos Notification Form Asbestos Project# r- Project Revision r Project Cancellation C.Asbestos Transportation&Disposal: (cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: RED TECHOLOGIES 203 PICKERING STREET a.Temporary Storage Location Name b.Address PORTLAND CT 06480 8603421022 C.City/town d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): MINERVA ENTERPRISES MINERVA a.Final Disposal Site Name b.Final Disposal Site Owner Name 9000 MINERVA ROAD c.Address WAYNESBURG OH 44688 3308663435 d.City/Town e.State f.Zip Code g.Telephone A Certification KEN FURTNEY KEN FURTNEY "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am PARTNER 2/16/2018 familiar with,the information Contained in this document and 3.Position/fitle 4.Date(MM/DD/YYYY) Note:Contractor must 7813372117 NESM,LLP sign this form for DLS all attachments and that, based notification purposes on my inquiry of those 5.Telephone 6.Representing individuals immediately 850 WASHINGTON STREET WEYMOUTH responsible for obtaining the 7.Address 8.City/Town information, I believe that the MA 02189 information is true,accurate, and complete.I am aware that there 9•State 10.Zip Code are significant penalties for submitting false information, including possible fines and imprisonment.The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Page 4 of 4 OF, 26 Ste,4 OP P ommmmmm mmmmmmmm OWN 11111MIMMINIMMIN ME■■■■■■■■■■■■■■■■■■■■■■�■■■■�■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ r■■■■■■N■■■■■■■■■■■■■■■■■■■■■■■■■■■■�.■■■■■.■■■ ■■■■■eNN■■■ ■■■■■■�■■■■■■■■■■■■■■■■■■�■■■■■■■■ ■■■■■■■■■■■■■■■�■■■■■■ ■■■■■■■■■■■■■■■■E■■■■■■ ■■■■■■■■■■■■■■■■■■NNNs■■■■■■■■■■■■■■■■■■■■■■■■ 1■■■■■■■■■■■■■�■■■■■■■■■■NONE■■N■EENEE■NEEEEEEEI IN■N■■NNNNN■■NNNN■■NNE■NE■NNONNOEN■NNEN■N■EENNEI INNO■■■N■N■N■■NNE■■■■■■■E■�NEE■N■NENEON�NE■EENNI �■■■■■E■■■■■■■NNENEOO■ENE■NN■ENON■■NNNENMENEENEI INN '■NE■■■N■■■■NNE■■E■■EEMENN��ENNE�ENN■■ENENEEN■EI ■NNNNE■■N■NNE■NNNN■■NN■NEEEEEEE■NEE■EN■MEMEEE■I ■■XIN■NNE■N■■NNN■■E■NNNNE■■■NNOENNEENNNNN■■■ENEI ■■N■■■■■N■ ■■■NNE■■■■■■■■N■N■EN�■■■ ■ENN■■■ ■■■■E■■■■NEM■■■N■■■■■NNM■■NENENNMENMNN■NMENEEEI ■■N■■N■■■N■■■EEE■M■EMENNENN MEN NNONE EE MEN EE■EEEi ■■NNE■■■■■■N■■NNN■■■■■' I'! ,!! EMINIMEMINIM MEN ■NN■■■■■■■■NN■NN■NNNI ■NEN■CNN■■N■N■■■■■■���■■■■NENNNN�NN■■N■■■N■NNE NENN:NNIMEMINVISNE■N■NN■ENE■■,, "1■■■l�barom■■■N■ENNEN■E■■E■ mmw- Ono W.Xww�mmwwm J�, ,•Rl�...II�..,.®w.�.�.�.n..�l�LwwsLrl�pw_ ww.._..w. GT/iA r D /SL.4 Mz-�' f � 1 f c.A y .coc US, �, -� _._ ���f �� Ns-�r' ,E" �!x-��� __...,.."' ( 3`�Vi eY�+%. is vE' Qc1"�\� vQ►� 11.3 / 4 t f �14'L" 16 4' ' r r 1 i '1p' ' 03 7 AW y/Z DR.<1 Fv All B Y 9 '9 -I--/--�-----Y� /.•.+.___/-.J._ /I /� `•A ,./rt -_ .•-. , .•-. -. �, �..ww+,4IF� .\ ��Li.,4 r�.`/'4..�l.4fi Mh ;, } "• �. �'...._"�,.• �� `"� /ZEr; �!V/� EjV�!/V - s 33 ,Avo ��