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HomeMy WebLinkAbout0152 CAMMETT WAY - Health L-1 5 2 CRRINVE%T G/Ay. /1YARDS%UNS (TILLS � A=^099-046 �. -, YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you, must do by M.G.L.-it does not give you permission'to operate.) You must first obtain the necessary signatures on thism for at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,.1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. Rna�,.,o x �,,,•-• DATE: f� Fill in leaser T i �� �:`: � APPLICANT'S YOUR NAME%S: 1 AAp ti`fn L9XF f5.'g1• iffli u�' i; �Yed�x o'er+�t1S�a ? i A' SINESS Y UR H ADDRESS: S Z C /►� - A� A!1 olJ ' .A m�t!Is•a�J TELEPHONE # ome Telephone Number NAMEOF CORPORATION NAME'OF NEW BUSINESS TYPE OF BUSI,NESS_' IS THIS A HOME OCCUPATIONS YES: NO ADDRES.S:-0`:BUSINESS., :... R ;,� ` a�l'� t A. J1`r.,MAP/.PARCEL NUMBER,,.,. .� When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of-the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING �.E �. — CO MISSI NER'S D FIC —, a �; i i rl t-I This individual h e ' ,, ,-,i. ...Cifr�YNt ra-i e� nf, of ny ermit req mements that pertain to this type of business. • RULES ANd REGULATIONS. FAILURE TO . u horize g a.t re** COMPLY MAY RESULT IN FINES. . C M E TS (;� Lh J l 2. BOARD'OF HEALTH This individual has can ' med of the permit requirements that pertain to this type of business. MUST COMPLY WITH ALL .HAMRDOUS MATERIALS WOATI01�lS.. Authorized Signature** . COMMENTS: 3. CONSUMER AFFAIRS [LICENSING AUTHORITY] This individual has been informed f o the licensin requirements t hat pertain gin to this a of business. P type Authorized Signature*.* COMMENTS: 7 TOWN OF BARNSTABLE Date: Z-/17 TOXIC AND HAZARDOUS MATERIALS ON W!�v "'Tn' ' NAME OF BUSINESS: -� (:57 /2—Tre-. Tf C-(\j I BUSINESS LOCATION: 15 2 CAnnnNc-hL!--WA jh�'l l5 INVENTORY MAILING ADDRESS: . k TOTAL AMOUNT- TELEPHONE NUMBER: OB 3bo 5 I 1 CONTACT PERSON: 111 CA Q U mA o EMERGENCY CONTACT TELEPHONE NUMBER: 508 260 51 l MSDS ON SITE? TYPE OF BUSINESS: 1--Lr0k ILus AIL INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides t NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW ❑ USED Degreasers for engines and metal °�,�,. ,.Printing ink Degreasers for driveways &garages Wood preservatives (creosote) goy aulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison"labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS icant's Signature Staff's Initial TOWN OF BARNSTABLE LOCATitON ASA C°Q m rn e e-t t W a S4 SEWAGE # VILLAGE fua►-s n s ho L 1,S ASSESSOR'S MAP & LOT 0-9:2 :26/6 i2o,4i1'7t*-, big v SEPTIC TANK CAPACITY LEACFENG FACILITY: (type) (size) NO.OF BEDROOMS 1 WMeB @R OWNER PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet ...7.1.7� 9M C��►..0 Lon{.inn fa�ilitvl I� Carn i .P ' ® IZi ' ��' NEW r.J 4 •.w.. 'f*OWN U;F Bi ti3TABLE r 20H AN 10 PM 1: 19 DATE 12/14/05 _ 4` �lSON PROPERTY ADDRESS John DeLomba 152 Cammett Way Marstons Mills MA 02648 On the above date, the septic system at the address above was Inspected. This system consists of the following: car' 9 O y� �. 1-100.0 ga. ion hept.ic tank., 2. 1- Dizt/z.i&ut.ion Box.,. ,3/;��/� 3.- 2-1000 ga-eion eeach.ing p.itz f Based on inspection, I certify.the following conditions: 4.- 7h.iz .iz a 7.itie Five ze/2t.ic: byzte.m (78Code) 5.- Selzt.ic zy-stem .i,6 .in /2/zo/2ea wo)zk.ing o/zdea at the /2aezent time., Oid ieach.ing pit .i.6 onP_y 12' �aom zw.imm.ing 12ooP. Z AJ� SIGNATURE Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc Address: P. 0. Box 66 Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 lmmnm CP. MACOMBER & SON, INC..n ks-Cesspools-Leachfields Pumped & Installed own Sewer Connections 6 Centerville, MA 026,32-0066 775-3338 775-6412 • COMMONWEALTH.OF MASSACHUSE�'TS EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ]FART A. CERTIFICATION gA 152 Cammett Way Marstons mills, MA 02648 OwmesNzme: ,Tohn neLomha Owner's Address:_cam_ Date.oUns :_1 911 4 105 Name ofl :(Pleaw Robert A Paoiini compmyN&me ,T_P_Ma nnrnber & Son Inc. AbftAddresw Rax .66 Centerville 1 MA 0-2632 T t b.WNmi*ww.508-775—a338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP sPpwedsystem bspectos pmsmnt to Section 15—W of T5b 5(310 CNE 15 OOM, The system: XXX Passes Conditionally Passes Needs Further Evaluation by the Local Approving Autbodty Inspector's Sipatcr'e: �n�j Driite: The system inspector shad submit a copy of this inspection report to the Approving Authority Ord of Health or DM 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 of we of firs DM The original should be sentt o the system owner and copies seam to the buyer,if applicable,and the approving authodty.. Notes and Comments report only dsserflies conditionsat do time of hapection,and unthr the condom of we at t ha time,T b inspectim does not mkiress how&e system wdl perform in am fet ore nuikr the same or dff not ce oos el True 5Inspection Form 61IN2000 page I Page 2 of 11 OFFICIAL INSPECTION:FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 152 Cammett Way ars ons mills MA 0264d Owner: John DeLom a Date of Inspection: 12 14 0 5 Inspection Summary: Check A,B,C,D or.E/ LA WAIF-complete all of Section.D A. System Passes:gEs NO I have not found any information which indieates'thit any of the failure criteria described in 3,10 CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Septic zurtem .iz .in 22one2 wo�tk.ing oaclea at .the R2eeent time., B. System Conditionally Passes: NO One or more system components as described in the"Conditional:Pass",.section need to be.replaced:o.r repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not-determined(Y,N,ND)in the for the following statements.If"not determined"please explain. NO The septic tank is metal and.over 20 years old*or the septic tank(whether metal or not)is:structurally unsound,exhibits substantial infiltration or exfiltration or tank failure:is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank,as approved by the.Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. 140 ND explain: NO Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled.or uneven distribution box.System will pass inspection.if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or feplaced ND explain: NO The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 f Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 182 Cammett Way Marstons Mills MA 02648 Owner:. John DeLomba Date of Inspection: 1 2/1 4/0 5 C. Further Evaluation is Required by the Board of Health: NO Conditions.exist which require further evaluation by the Board,of Health 4n order to idetermine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which.will protect public health,safety and the environment: n 0 Cesspool or privy is within 50 feet of a.surface water n o Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: n o 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. no The-'system has a.septic tank and SAS and the.SAS is'within a Zone 1 of a.public water-supply. no The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well. n o The system has a septic.tank and SAS and the SAS is less than 100 feet.but 50 feet or more front a private water supply well". Method used to determine distance 2).i-3uai _ "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 152 Cammett 'Way Marstons Mills- MA 02648 Owner: John DeLomba Date of Inspection: 12 1 1 4 1 n 5 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"..to each of the.following.for all inspections: Yes No _ X Backup of sewage-into facility or system component due:.to overloaded.or clogged SAS.or cesspool - Discharge:or ponding of effluent to the surface of thel ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an over or clogged SAS or cesspool. X Liquid depth in-cesspool is less than 6"below invert or,available volume is less than'/2•.day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply.or tributary to a surface water supply. _ X Any portion.of a cesspool or privy is within a Zone t of a:public well.. —7 Any.portion of a cesspool or privy is within.50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater.than 50 feet from a private water ! supply well with no acceptable water quality analysis. [This system.passes if the well water.analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates.that the well is free from pollution from:that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered:A copy of the analysis must be attached.to this form.] NO (Yes/No)The system fails.I have determined that one or more,of the above failure.criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner ibould 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 10,00.0 gpd to 15,000 gpd• You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1512 cammett Way Marstons Mills MA 02648 Owner: John DeLomba . Date of Inspection: 12 14 f 0 5 Check if the following have been done.You must indicate"yes".or"no"as to each,of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal.flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of thi..s inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS,located on site?. X _ Were the septic tank manholes uncovered;opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at.�he Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 1 . Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 52 Cammett Way Marstons M1 s MA 02648 Owner: John DeLomba Date of Inspection: 1 2/1 4/0 5 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): . 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMA 15.203(for example:110 gpd x#of bedrooms): 3 30 Number of current residents: 4 Does residence have a garbage grinder(yes or no): rz o Is laundry on a separate sewage system(yes or no):no [if yes separate inspection required] Laundry system inspected(yes or no): n 00 Seasonal use:(yes or no): n q 2 0 0 4=11.6, 0 0 0 G%D=317..E 8 0 Water meter readings,if available(last 2 years usage(gpd)):2 0 0 5=16 5, 0 0 0 4 5 2.,0 5 G%D Sump pump(yes or no): no Last date of occupancy: p.¢e z e n t COMMERCIAL/INDUSTRIAL N/� Type of estab.'"lment: Design flow(ba ed on 310 CMR 15.203): ___gpd Basis of desip"flow(seats/persons/sgR,etc.):. Grease trap present(yes or no):_ Industrial waste holding tank.present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 9/1/05 12umI2 7 maint macomgeic Was system pumped as part of the inspection(yes or no):no If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: . TYPE OF SYSTEM X Septic tank,distribution box,soil absorption.system _Single cesspool Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 10f yeaaz Were sewage odors detected when arriving at the site(yes or no):n o , 6 r Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 52 Cammet-t Way Marstons Mills MA 02648 Owner: John DeLc)mha Date of Inspection: 1 2/1 4/()5 BUILDING SEWER(locate on site plan) Depth below grade: 3 0" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): loint,3 aRR eaa tight-., No fnrzknap_, Vented thorough houze- vent.- SEPTIC TANK:yES(loeate on site plan) 100 0 ga io n-6 Depth below grade: 2' cove It t o ga a d e Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8' 6"X5 8"X 4' 10" Sludge depth: t a a c e Distance from top of sludge to bottom of outlet tee.or baffle: to a c e Scum thickness: t¢ace Distance from top of scum to top of outlet tee or baffler bz a c e Distance from bottom of scum to bottom of outlet tee or baffle: tea ce How were dimensions determined: m e a 3 u 2 e d Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid.levels' as related to outlet invert,evidence of leakage,etc.): um tank eveaU 2 u a T Pv t R. tees ate peace., Tank 7z .s auc uAa zy zoun , GREASE TRAP:n o(locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert evidence of leakage,etc.): gzeaze t2a/2 i.6 not /22eze-nt . 7 Page 8 of 11 OFFICIAL:INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 152 Cammett Way Marstons Mills. MA 02648 Owner: John DeLomha Date of Inspection: 1 211 4 f n c; TIGHT or HOLDING TANK: NO(tank must be pumped at time of inspection)(locate on site plan) Depth below grade:. Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): Tight oa ho2d.ing tankz ate not /22ezent DISTRIBUTION BOX:y e.6 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 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.): a age in oa ou o f P.oz., PUMP CHAMBER:n o (locate on site plan) pip Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pump chamgerz .iz not Paezent 8 i Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 152 Cammett Way . Marstons Mills MA 02648 Owner: John. DeLomba Date of Inspection: 1 2/1 4/0 5 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Located .6ee page 10., Type X leaching pits,number: 2 Oid /r.i.t .iz on.2y 12' �2om zw.imm.ing itooe leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Loamy .to medium fine znad.. No zings oO -,,a.i.euae o/t /rond.ing.,So.i z ate dsy.• Vegetation .is hoama2., CESSPOOLS: n o (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes`or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): ceas/roo$rs a/te not /raezent PRIVY: n o (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.): R1"W i.s nol ARP.tvnf 9 II Page 10 of 11 OFFICIAL INSPECTION FORM,NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE;DISPOSAL SYSTEM INSPECTION:FORM PART C SYSTEM INFORMATION(continued) Property Address: 152 Cammett Way Marstons Mills MA 02648 Owner: John DeLomba Date of Inspection: 1.2 14 0 5 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks:Locate all wells within 100 feet.Locate where public water supply enters the building. s 10 , I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) . Property Address: 132 Camme wa i& Marstons Millc MA 02648 Owner: John DeLomha Date of Inspection: 1211 d/a; • w SITE EXAM . Slope Surface water Check cellar Shallow wells Estimated depth to ground water D feet - Please indicate(check)all methods used to determine the high ground water elevation: •NO Obtained from system design plans on record-If checked,date of design plan reviewed: u e z Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local-Board of Health-explaiwei.s 9./.i.P pezAd ~ n o Checked4ith local excavators,installers-(attach documentation) Accessed USGS database=explain•t tp t t o wn.,&a anz t a I ie.,m a.,u.6 You must describe how you established the high ground water elevation: ll sed. : Cape Cod Comm.i s.ion Yqt en 7aa2e Coritouaz And Pugtic Uatea Supply Vaii head paoteet.io•n a/teas map.. Sent 1995 Vat ea ae souace s 0411 ce cage cod commizion T1 up of Cround o� V Leaching Pit q : ;eet Groundwater:6I Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method q-� Therefore,the vertical.separation distance between the bottom, I of the leaching pit and the adjusted groundwater table is eJA)Pf T I.SI feet: � • bid �� is � . 5-7 11 . MMTW'_�"'"����� 'fUWN OF MARS TONS MILr,S I30ARU OF III+ALTiT SUBSURFACE 9F.WA(iR IITSI'USAL BYSTEM INSPECTION FORM - KART D CERTIFICATION •'•T��•'St�T`•M���'��'� '�� ^� -TYPE OR PRINT CI,EARLY- ' PBQPERTY INSPI<=0TLrD , 1S2 Cammet Mills STREET ADDRESS • A'SS•ESSORS MAP, DLORK AND 'PARCEL $ OWNER's NAME John D PART` D CPsRTIFLCATION ' Ro jea�t f?a.o.$tn i NAME -OF INSPECTOR COMPANY NAME obe Ah P.., Naeom8al-2- Son Inc Box 6 6 Czn�envil is Nabb- 0,26'32 ` COMPANY ADDRESS Town or City •- staLt t:1P strQaS COMPANY TELEPHONE ( 508. Y �73 - 3338 FAX (' 508. P90 � f 578 CERTulCATION. STATEMENT i. .certify that. I have personally .inspected .the sewage digpoa3a`1. system at i nt this address and that th$ information rTperins e�tiQnep.wasaperformednand any omplete as of the tithe .. f�inspection.. The F recommendations regard•it� iencedin thenproperefuncti-on- arid maintenance ofon- with my training and exp.gr site sewage dtsposal sy ate ms • } it�i„�• Check one: ' Systed PASSb , The inspection whic.M 'I have conducted has .,n-vt found any information which indicates that the s' tqm fails to adequately. protect .publi•o Itealtit or the envlrvpment as defined in- .310 CMR. 16:30.3's Any f1tiltu're criteria Uot evaluated are as staffed in the FAI�LUIt CRITERIA section o:f this. form. _•�__, System FAILED* t ' The inspection wtlictl I }tays as ted -has 'found that the System fails to protect the public health and the eni>4ronmen•t ' in aevord•ance with T4tle 61 310 CMR 15 . 303. and as - specifically noted on PART, 0 FAILURE CRITERIA of this ins ' c'tion .fo Ins.pector Signature- 'Dat# 12, ne Copy of this certi,ficat•i•o7n must 'be provided 'to the .QWNSR•i t�h BUYER where uppli'.aable) and th?. e 13PARD OV HgALTIi. ,. „N,.» , * If the inspection FAIL'Eb., thb owner' .or operator 'e'hal3, . upg'a:ads'•the eyetem. within obe year of the da't•e of the inapection, unless. allowed or- required nt.horw{se as Provided in' �110 CMR TOWN OF BARNSTABLE LOCATION ��� ��/11/1� ����I� SEWAGE # VII LAGE .�' �� :� ASSESSOR'S MAP &LOI 2 `� 7(b INSTALLER'S NAME&PHONE NO. ��.�`.��C. LI-1 -7 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) F;03- NO.OF BEDROOMS BUILDER OR OWNER �I5�1� p. i V es r,-�.� C, PERMTTDATE: 10 9S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet o ea Mint"ility) QFeet Furnished by �%a. �� .-i J� r i a a rr' r THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE AvOration for Biopwial Work.6 Tonotrurtion Permit Application is hereby made for a Permit to Construct ( , ) or Repair "t--'5_an Individual Sewage Disposal System at: Sp� wQ v t \ Location-Address .--` •--._.ram/--{11._1. -.t,-------------------------------------- ----------V dam.------ Ocvnc p ^ Address w � . __ �: -� -►tea, - - `'� s = ,�►M - Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- ---------------------------------------------------•--------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow.....................................,------gallons. WSeptic Tank—Liquid capacity------------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 tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date....................................... Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-.--____-..----.-----_- fr4 Test Pit No. 2................minutes per inch Depth of Test Pit-.--_---______-_-- Depth to ground water_--___-.._--•----_-_-__. 9 ..._....•--------------- ------•----........--•----------- •--•-----•--•-•-----•-------•----------•......................................................... 0 Description of Soil....................... W .......44 ,..E -------------- --------------------------............................................................... W x -------------------------- ----------------•----•--.......---.....--------------------------._...--•-----------•-----------------------------------------------------------•-•-•--------•-------•----•-- UNature of Repairs or Alterations n wer when applicable.-.-------7.1­._ .......... e_.'................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code The undersigned further agrees not to place the system in operation until a Certificate of Corn lance has been issued by the board of health. I �d -^—%�-4-------------------_..... / .................................. Dare Application,Approved By ............. - ------------------ ---------------------------- ----------------------------------_. .[o.. -` ------ Dace Application Disapproved for the following reafonf: .............-------------------------------------------------------_----------------------................................ -----...........................-------..............------------------------------------------.......----------------------------.._.............--------------------------------.........- ----t.o.---- Dace Permit No. ----------- ......I.7V----------------- Issued /® � 3..`�13 Dace l C� �,� 0.rs No........ ••---- I - F,,.3o.......ao_... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN .OF BARNSTABLE 'Allp irativit for �i!ipwial lVnrkii Toustrurtion Prrmit Application is hereby made for a Permit to Construct 4 PP y � ( ) or Repair `+�an Individual Sewage Disposal 1 System at• �n j1 j )r Y 1 _ _ . � / s r _:doh.+.. --..1__-f Location-Address �/' ..t .�n.�ca C :....... IS �` C.�,:►- - -No � nl �.�1 s , Owns 0 ,�• Address W 4•�-� .x..,...-� :� -`--------_--- Q ' �� 5 'Y1�_S .A�-� , w1 C Installer Address UType of Building 0 Size. Lot............................Sq. feet .-t Dwelling—No. of Bedrooms-----•-------------------------------__.._Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Buildiu yp g ____________________________ No. of persons____...-_.__________....__-. Showers ( ) Cafeteria ( ) d Other fixtures _-------_-•--------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow.-------------------------------------------gallons. WSeptic Tank—Liquid capacity------------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 tank Percolation Test Results Performed bY-------- ----------------------------------------------------------------- Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit_-------------------Depth to ground water........................ P4 .......................................... D Description of Soil....................... ` -�--- --------------- ......................................................... ........................................ -------------U � - ----. _ .'' - - ------ ---- - - U Nature of Repairs or.Alterations n wer when applicable______.: .. .-��A--N---. ,. . ---- -- �?-�d----•---L._e.... ;rer w The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code=The undersigned further agrees not to place the system in operation until a Certificate of Com.. iance has been issued by the board of health. ,d Si ID�-w._ - G •> ..: ID 1� -------------- Dare Application.Approved By ..._.............. ---.:....,... -------------------------------------------_-------------------------------..._..----------------- 10-41-94........... Dare Application Disapproved for the following reafonf- --------------------------------------------------------------------- ..----------------------------------------- --t.b..-.;t. _.-.5..r. Dare ,. Permit No. ...... -- -- --)7 /- ---------------- Issued ........ '9 ...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CIlEr#ifi ate of Tompliance ?NIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by t... - ---------------------- .NAJ - - : tLS ------- ---- ---------------- Installer has been installed in accordance with the provisions of TITLE 5.of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..----------------------------- dated ------------...._........................... THE ISSUANCE OF THIS.CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. -�� DATE----... .�'" ./ -- -- ----------------- Inspect - - �" �' --- -w—w:_--i.r----,-----.W--3————————— e--ems..ern—u-------.--w—r>:c—..w---tom_--------m---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 9 TOWN OF BARNSTABLE s �� No._... .ram.. � O FEE........................ i n tYr� �u�t tr rtilart rrmit Permission is hereby granted. ''t `^ .�.....=-......r.......................................................................... to Construct ( o Re air (tip^)¢n Individual Sewage Disposal System atNo...............I . 4...! a... -- m. 0 5---,...... ` ----------------•--•--- Street as shown on the application for Disposal Works Construction Permit N010 Dated-----IQ-Al-9s'....... .................................. b�- ;!�'��----------------- Board of Health DATE-•P..---A ---- - R, ....'......••----••--•-------... FORM 36568 HOBBS a}WARREN.INC..PUBLISHERS 3 i r�i�(�GrI �W ram. r�MP�' 74J •s ,� ! If 1 W O S'•�' X %� � � �I r�M 1 fiii '• ay�' �� r• ",t � "''��l�►'Q' �`'��'"'.�',C t��,�iv:� � ' °�• � ���.�' � �`�- Lai 71 & a 20 aio sib.Fr TH 't t, � Ull� WIILIAM iVo: 2J7� •t, � I� � � ; Yin Lai si"'ge't— wo 71 "$"' �l "'ie��•'�;;?�}$L �,"�F� 1 1 , 19 o 7 MAY z, rj gS .J ,t.A"4.NY y�.n�:l'Y•'•,';.t. \ i 1L (yam '� ! Mo win rY`+ hF � 'rl� 4V7- 0 _ c5 LOCATION �3#�S SEWAGE PERMIT NO- -Pf,r 7/C,-.n�rgcri w.4y �S`- 4/.3e 'VVLLAGE �INyySTA LLER'S NAME D ADDRESS \ 7 1 49'2 N '�'-sU1LDER OR OWNER DATE PERMIT' ISSUED 5--Z DAT E COMPLIANCE ISSUED GAr>>Al _.y QS, REA-� I /6 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...----- -- ..........................OF........................................-----------.......--------------------........--•- Appliratiou for Disposal Works Tnnstrnrtinn ".tram# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual,Sewage Disposal System at: 7 Location-Address or Lot No. --.. ...---- Owner Address Installer Address U Type of Building Size feet Dwelling—No. of Bedrooms._---S.....................................Expansion Attic ( ) Garbage Grinder ( /�� `4 Other—Type ype of Building ... tk ES'�'s�._..... No. of persons.__._...��................ Showers ( ) Cafeteria ( ) Otherfixtures ----------------------------------------------•--------•-----------------------•--•-•--------- Desi Flow-----•-- -� ----G--.- 0---••---•••...gallons. W 'gn ._ � ��_gallons per person,per day. Total daily flow------------- _ WSeptic Tank—Liquid capacity.lb O:Qgallons Length_q'.4'_1... Width----*. -.7'tDiameter................ Depth................ x Disposal Trench—No. .......... ..... Width_.I................ Total Length.................... Total leaching area--amO.....sq. ft. Seepage Pit No---)............ iameter------ Depth below inlet.... Total leachingarea....... Z Other Distribution box ( � Dosing tank ( ) 0.4 Percolation Test Results Performed by.----------(�_ �}--W-------------------- - Date......... �..�•,�__I,, ...... Test Pit No. 1_ _ ....minutes per inch Depth of Test Pit.----t�........ Depth '* ground water.....t��p�9._...___.. 44 Test Pit No. 2...4.:�.minutes per inch Depth;of Test Pit----1.2„_o_._.. Depth to ground water-----I.v A....._... x Description of Soil------1--•_... 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 iITLB 5 of the State Sanitary Code,—The undersigned further agrees not to place the system in operation untila Certificate of Compliance has e n 'ssued he boar f health. ` Dal � A plication Approved By..... ------- Date Application Disapproved for the f olloz g reasons:.............................................................................................................. ....................................................................................................................................................................................................... Date Permit No......IS. — � � =� ................:.. ------------------- Issued_ M Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF......... ...................;.......----------------•---.....................-------- Appliration for Uiipnsal larks-�C�nnitrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: • . ......Loc., "on-Add ess,,,, •---:.. .- ---- ••-------•---- . or Lot No ...... Owner Address -------------------- ----------------------------------------------•...--------------------------..... Installer r' Address Type of Building Size Lot.;XQ.L)Q.()_..Sq. feet a Dwelling—No. of Bedroo s ............ _._..Expansions Attic ( ) Garbage Grinder ()IJO aOther-- Type of Building ...... No. of persons._ ._-3_--_-_--•_----- Showers ( ) — Cafeteria ( ) dOther fixtures :-: ---------•---------------------------••---. -------•---•-••---. -•--•--------•----• ------------------......----------------- W Design Flow...... 'Z - gallons per person pet day. Total daily flow............. 3..0...............gallons. WSeptic Tank—Liquid capacityl.Q Cgallons Length . Width _ Diameter________________ Depth...... x Disposal Trench—No..................... Width.:r---------------- Total Length Total leaching area__�U.0------sq. ft. ;N •--.......... Total leaching area....... ----------sq ft.Seepage Pit No. iameter.....4.......... Depth below inlet Z Other Distribution box ( Dosing to ( ),- ~' Percolation Test Results Performed by__.......... _: _ .................. Date.... ` *.� a Test Pit No. 1 _ '._..minutes per inch ,.Depth of`Test-Pit. Er,_..._... Depth to ground water, .!V`!� _.._.__. f� Test Pit No. 2--4- ..minutes per inch Depth of Test Pit_.__ . .......... Depth to ground water...........-... .___. O Description of Soil " = 'ar,� - 0 F--� --- w ..... ^ �6 .q , a, " 1 ----- — ................... ------------------------------------•---------------------------------------------------------.._.... ------------.....-----•------•----------•--------------••--•-•••-......------•----•---•-------•--- U Nature of Repairs or Alterations—Answer when.applicable_________________._..:........................................................................... .....-•------------------•-•-----••-••--•---------..._..•----•----•--------••-•--................................ Agreement: The undersigned agrees to install the. aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until/a Certificate of Compliance has a n.'ssue�Ie boar f health. G L igned .. .............. .... Da Application Approved B PP PP Y . . •---• ------ ----- ----'--- Date Application Disapproved for the f ollo ng reasons:---------•--------------------------------------------------•-----------•---••---•- ::=-------------------------------------------------------•---------------------------------------- Date to- .................................... ssue . •--- Permit No........ 3 - Id_ ------ -------•- ... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.... ............................................................................... �rrti�irtt�r of �unt�li�tnrr THIS IS TO ERTIFY�Tlh the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Installer at------- "--- - ---------------1 I--- has been installed in accordance with the provisions of TITLE 5 State Sanitary Code as described in the application for Disposal Works Construction Permit No---- _'-l.. . ............ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............ ' . .. ..._ Inspector .......-•--.------ • 4 THE COMMONWEALTH OF 1ASSACHUSETTS BOARD OF HEALTH :. No OF...... ---...••-•-...••--•-•-•........ FEE... Disposal or D n in entt Permission is herebygranted.......................... to Construct ( ) or Re air ) an I dividual Sew ge Disposal System E� V"r atNo•----------tip r 0't•------------.1 4------------- - ------ -- ----------- -•---- . --------------------------------------------•-•-...... as shown on the application for Disposal Works Construction Per it No.,,,..____ Dated:.................. .............................. at e DATE.................................................. ............................... FORM. 1255 A. M. SULKIN• INC., BOSTON - 1 : S/N6L.:E f<tiy/L Y -- 3 BE0�2oowt A10 GL72BA45E G•e%t/OE.2 LoT-'.7 I- rr(,L lAT6S OA/LY FI-OW _ SEGT�O T.4N� = 3.�4X/SO o =�y�•G.Po - j zs.v0 - - _�/SE d/.S�12S,GL P/T•—USE /4G0 6.4/- . qS-4 714, I loo,z LoT 71 PkoP 0 Gt7or, p 2 .F rAu�- o r :.7-oT.QL. �.4/Lr�LoK/� t334 6..w. OES/G�'•� PE.2CpL,4T/aN.2,4T�:' TH Z E s ��s� � `- ..:.. . , 3 PWU�NEr vA OF tid<,s��� L Do o PETER EIEAN s�'s W ILLA cfl /o u, , U No 2973 �` N.Y E So'a' is 1 .o �? Na. 1933440 IST CL � ,,.,.,... lva. om CAMMtrTT' VGA DAMES Gonlah�PG�I=R.:SuC�(.�vq►.J .4.z o 8 FG• /cc) t 49 2 /./ of8.Z Sv��So�Z� /vow ( f�" OAST, l /,ODO /w. z . . Fl•972.77 6.dG. /y✓ BOX /N✓. GAL, 09 , tBaca.Pir.• g7Z 9i7-k sEPrrC 9g. w--/ %7XV• T�.✓.�c M E •• sNE 974 97.6 G'E.2T/�/EO PG OT PLA�t/ JAND ,c ;moo Sd pA7T.— Z� Ile, PGQN ,2EFE,2E�t/C� �C. ,29 So o � s�a8c-r 2 _ LAI w.ayTL�7v �Zop o s L / LE,eT/Fy Tf/.4T'THE DwA l.G kG S/leWV 7 / h�E.c�Eov co.+�P�Ys W/�-s/T,y�'Sio��✓,uE B�+xTE,e�.vyE /.vc. .d/t/1�.SE'T�/1�lO .2EQV/�E�I�NTS 4� Th'E .2EG/sr�ecl.CQi�O.SU,2tiEyO,�S roxiv of 8,4)1 S7�)8 LC Qlvz? �- LocaTE.O Toi-IAI D4 L o N 8,q a.v AAX ilY.sT,e- s -t/.sfE�YT.sver/�'Ysl�c/O T//E o��S�T,s I Sh�K/�yE,2�4N•S.��UG�it/�TGtE lJ.SEp CFATERVILLE-OSTERVILLE-MARSTONS MILLS FIRE DISTRICT 1875 ROUTE 28 CEUTERVILLE, MA 02632 (508) 790-2380/FAXO(508) 790-2385 OILMAZARDOUS MATERIAL RELEASE FORM F.A.#��s LOCATION: ADDRESS OF RELEASE- 159 n .W.._L t n L u�' Vv_ nni,.n GATE OF RELEASE: PRODUCT RELEASED �a �.� s�i_b oil ESTIMATEDQUANTITY• CORRECTWE AfTIaN TAhN BY RE9POISSKE PARTY:n-- -l----- NOTIFICATIONS: FIRE DEPARTMENT: YES,�X) NO( ) GATE'tsco c TIME NATIONAL RESPONSE CENTER YES( ) NO�X)v-,DATA. v TIME DEPT.OF ENVIRONMENTAL PROTECTION YES( ) NO(XX) DATE TIME • OIL SPILL COORDINATOR: YES( ) NOfX) DATE: TIME: TOWN BOARD OF HEALTH: YES( ) nNG-, X) DATE: TIME: TORN HARBORMASTER: YES( ) a DATE: TIME: OTHER AGENCIES: , , .,..r�.., ...� ... ,., ,,.,....won, ........ ....... ., . . .....,.. ..ut f r-,.. ....c i....,i.g ___ _ _ i- .en,_. COMMENTS , •A i REPORTED ^ .. DATE• y �I WHITE COPY-FIRE DEPARTMENT YELLOW COPY-G.E.P. PINK COPY BOq OF HEALTH C-O-MM FORM 058