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HomeMy WebLinkAbout0195 ROUTE 149 - Health (2) �. f Commonwealth of Massachusetts �8-�8 1VD 0 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9c°M 195- Unit B Herrring Run Place Property Address Randy Cox f� Owner Owner's Name 'information is required for every Marstons Mills MA 02648 / page. City/Town State Zip Code Date of Inspection t',41 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information / Q/ � on the computer, l `! use only the tab 1. Inspector: key to move your cursor-do not Greg Brehm use the return Name of Inspector key. Bennett Environmental Associates Inc. Company Name P.O. Box 1743 Company Address Brewster MA 02631 City/Town State Zip Code 508-896-1706 13633 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Fu h r Evaluation by the Local Approving Authority Inspector's�gi'feature 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 DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Ve page1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 195-Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town 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: ❑ I 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: 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 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. ❑ Y ❑ N ® ND (Explain below): There was at the time of inspection, a garbage grinder present in the kitchen sink. The design plan states that one is not permitted. The homeowner was going to have it removed. See attached photos from the homeowner showing removal. No other failure criteria described in 310 CMR 15.303 existed at the time of inspection. The system appeared to be working as designed and functioning adequately under current use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 195 - Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 195- Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 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 must 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 Y day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 195- Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town 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 cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. 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 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 195- Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �qM 195- Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town State Zip Code Date of Inspection D. System Information Description: Omni Recirculating Sand Filter System with engineered design plan By Christopher Costa& Associates of East Falmouth, MA dated 12-6-02: Comprised of a 1,500 gallon septic tank, a 1,000 gallon recirculation tank, 2 OMNI filtration modules, 250 gallon pump chamber, and 2 leaching trenchs that are 2.7"W x 32.51 x 2' D . Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): See Details Detail: 2013= 66,000 gallons= 180.82 gpd. 2014 = 95,000 gallons =260.27 gpd Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 195- Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None on file with Town Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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/Alternative 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): Pump chamber to leaching trench. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 195-Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 11/08/2002: Town of Barnstabel Certificate of Compliance dated 11-08-02. Disposal works construction permit#2001-393 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: e0t Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints and venting were inspected and are in working order, no evidence of leakage encountered while inspecting main sewer line. Septic Tank(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1,500 gallon septic tank with outlet riser to within 6" of final grade. Schedule 40 PVC inlet and outlet tees functioning correctly. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,500 gallon Sludge depth: 10" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 195-Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Tape measure, sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not recommended at time of inspection. Inlet and outlet tees are functioning properly, septic tank is structurally sound. Liquid levels as related to the outlet invert was at a normal height. No evidence of leakage or backup observed while inspecting septic tank. 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 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 195- Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 - Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 011 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No D-Box Present-Pump Chamber to Leaching Trench 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.): 250 gallon pump chamber is operating correctly. Riser and cover to final grade. Pumping not recommended at time of inspection. Pump, on/off float switch, and alarm float switch are functioning properly. Audible/Visual alarm operating properly and is located in basement utility room. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 195- Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2, 2.7"W x 32.51 x2' D . ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil is sandy, there are no signs of hydraulic failure now or in the past, vegetation normal. No inspection ports or cleanouts to final grade for pressure dosing trench. Vegetation is normal in the area of the leaching trench, no signs of hydraulic failure present at the time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 195-Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 195- Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 195 - Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 51+ 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 determination was accomplished using percolation test data from the Design Plan By Christopher Costa &Associates dated 9-12-02. Soil Testing was conducted on 3-24-98 Taken By: Bruce Murphy and Observed By: Jerry Dunning. Soil test logs indicated that no groundwater was encountered at elevation 45.3, the bottom of the leaching trench is at elevation of 50.2 which leaves a 5'+ estimated seperation to high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 195 - Unit B Herrring Run Place Property Address Randy Cox Owner Owner's Name information is required for every Marstons Mills MA 02648 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 / �, u No. ,• - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS Opplicatiou for Migogat 6potem Conotructiou Permit Application for a Pernut to Construct( /)Repair( )Upgrade( )Abandon( ) [RIComplete System ❑Individual Components Location Address of Lot No. POLife— /L1g MarwonS Inrlls Owner's Name,Address and Tel.No. Assessor'sMap/Parcel 1�4m //om 42ealfy 7- Assessor's `7 8�/f Can��' / P O /.fox V /-/ ann;s IM 30i-Z l--35 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �C[r/ )a1/OSS�,Tr �G�-�``��- 133 �3�5 ��'s�yn, _Inc, 54�-.5y0-�s6d5� A57 Pa/n7el- Ave FCj/n70u7t-/ aA /6 yl(a1/errin e Zef 6a feS.Al fa11V0a7 i IM Type of Building: Dwellin No.of Bedrooms 3 Lot Size. IZ,� sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow e_215 gallons. Plan Date' n// o�7 DRDUO! Number of sheets �i Revision Date Title rht��' /,lac) A'rnPo59d Nd&_rC qe 5ali,51[ykne, S� G_Sa S Size of Septic Tank d (554Aloa // Type of S.A.S. Description of Soil U - g ' "MY ' al/)C -�3o - /3-� " e m �d;am .a m Nature of Repairs or Alterations(Answer when applicable) Ale-JU 6012_51- aCI ors Iiv`" :n11l�dG Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to pl system in operation until a Certifi- cate of Compliance has been i ued bv this oard ealtlr. Signe Date�L/ 17 J,()7 Application Approved by Date Application Disapproved for the following reasons Permit No. I O Date Issued --------------------------=------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, NIASSACHUSE GNING ENGINEER MUST SUPF-Rvisi-: MaiALLATION AND CERTIFY IN WRITING Certificate of CoMpliatI SYSTEM WAS INSTALLED 11� STi k�IC'T ff>.,GOANCE` o P . THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed )Repaired ( )Upgraded( ) Abandoned( )by at \��\ �' L\�1 _ has been constructed 'n accordance with the provisions of Title 5 and the for Disposal System Construction Permit No� 1" �� S dated (a Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector ------------------------------------------- Type of Building: Dwellin No.of Bedrooms 0 Lot Size Z/y�sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 34 gallons per day. Calculated daily flow 338,215 gallons. Plan Date' a 00© Number of sheets Revision Date Title Jp u' Yomwspd 110ase qe- St? I GSa S Size of Septic Tank /,!5La e-;6i/long Type of S.A.S. Description of Soil o — S 1/)/�i/ l)a m `r3 z da/» V SQ/7 Nature of Repairs or Alterations(Answer when applicable) Aleuej don S1-/',LIch*on R,C-S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to plre=ft system in operation until a Certifi- cate of Compliance has been i uedpythisBoard ealth711 Signe. Dated✓ _ I()irApplication Approved by Date Application Disapproved for the following reasons Permit No. o` x Q @ 1 Date Issued `'D --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS NING ENGINEER MUST IISS BARNSTABLE, MAESACHUSE J �ZLATION AND CERTIFY IN WRITING e E SYSTEM WAS INSTALLED IN 'STRICT �ertif f c�cte of �Com��pYt u';�C0f3 AN0R To P THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed)Repaired( )Upgraded( ) Abandoned( )by at k VNl 1 1°i d`1 lulu has been constructed 'n accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoC S� ' 3��S dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector . --- _--- _ _ _-- _ ---_ ---- _ —— — No. �' Fee coc . THE COMMONWEALTH OF MASSACHUSETTS a ` PUBLIC HEALTH IVI�I®N EARNST'AULE} MASSACHUSETTS z. t! igp000, Opotem Conotruction Permit Permission is hereby granted to Contract_.(, _Repair( )Upgrade'( )Abandon( ) System located at' !- ( ; 1 an(has describ d,in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to �comp': �1 �� tie [lowing local provisions or sp�cia lconditions. Pr?vided:�onsfinB n �us' e corxi 1 to wiYhin,three ears of tlie4date of thrr errriitl +. 1 t 11 i „r C,4. ` As Dater at ., hr >t Approved by t . � �l_a..�.✓ vEM'. r 1 . TOWN OF BAPNSTABLE i% LOCATION �D '. J<c:` ;i ;as, ,{= SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 7 /� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY/, a 0 r. .U.,,C �� II —'154ru LEACHING FACILITY: (type) (size) -^ NO. OF BEDROOMS BUILDER OR OWNER :z PERMITDATE: COMPLIANCE DATE: 1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on.site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within.300 feet of leaching facility.) Feet Furnished by � �•_ __ s-s ;fit �`,�-;.,�^ �� - ,�� � i '_. o 3 .. m f,F • i MAY-02-2012 10:17 From:BARNST HEALTH 15087906304 To:5088965109 P.2/8 r �j ; r 17 r =" " 'i 1-•} � raj 1 �k ' _ � . �•.�"' .l.a�5,��' �,.y ( fug 'rah �•t /J,�''t.. /SL� C J ' Iqq TOWN OF BAR.NSTAi3LE LOCATION / .r .r'' �; 3r'�. SEWAGE#i tU 1 �=� ASSESSOR'S MAP& LOT 2 g(9' ACrE '"�r INSTALLER'S NAME PHONE Na. Cam'��� r"Y''Yr7; t�"aj� ''�ei7 SEI'TiC TANK GAPAOI'I"Y,� z3 cj T '�� " ` "-fUf J (size) "7 I'' '' LEACENG-FACILITY: (type) NO,OF BEDROOMS-.--. BUILDER OR OWNER PERMITDATE: . C{]MPI,IANtyE DATE: 1 Separation Distance Betwctn the: Maximum Adjusted Groundwater Table to the Bottom of Lett Mng Facility Fmt Private Water Supply Wall and Leaching Facility (If any wells exist- Feet on Atc or within 200 feet of.ltaching facility) - - Edge of Wetland and Leaching Facility(If any wetlands exist widen 110 feet of leaching facility) Feet lFurnished by W.VERNON WHITELEY, INC W. VERNON PO Box 1266 r o A•v West Chatham, MA 02669 INC. " PLUMBING • HEATING • AIR CONDITIONING INVOICE Bill to-.' Randy Cox Invoice Date: 11/05/15 Po Box 1418 Invoice#: 00008108 Marstons Mills, MA 02648 Perms: Net15 Service at: 195 B Route 149,Marstons Mills Work order: WO-00008281 Reason:.Remove garbage disposal for sale of property Work Performed: 11/4/15: Took material list, need to return in the morning to remove disposal 11/5/15: Removed disposal and piped new drain. Product Date Comment Ruant Unit Price Disc% Amount Technician-Service Labor 11/04/15 Site visit-no charge 1.00 125.00 100 $0:00 Technician-Service Labor 11/05/15 1.00 125.00 0 $125.00 Pvc P-Trap W/Co 11/2 Pvc Trap 1.00 8.86 0 $8,86 Branch Tailpiece Chrome 11/2"X 8" 1.00 1 33.22 0 $33.22 Basket Strainer Ss 1.00 25.98 0 $25.98 Pvc 4511/2" 1.00 1.80 0 $1.80 Ma sales Tax 1.00 4.37 0 $4.37 TOTAL. DUE: $199.23 "NOfV5 Phone: (508)945-1100 **Family Owned Since 1952** www.wvwhiiteley.com ka kor T�f4 New q a, ss; .. s ++ketiofp, ' vim.. ....,.y C a � Y A 4 9 4 z' ° Or ev t5, �' 9r ! ✓" t �. J ' a1-4 x c "fir x n fi s era �� y�" a F a'a � .p a r $X� � `ry%3"' '^ -.>.. � � _ ,a°w•'v„u, �� ..h s�,ta. s+s sx.. .:. c .� �,, R ,ka� 9 ,�' Poulos h e v YaL Sfi NOT �x r F y pxf Owlfq e tea' a ..ems.- - r ] a ! a# 4 Afi•- BENNETTENVIRONMENTALAsSOCIATES,. INC* . LICENSED SITE PROFESSIONALS A ENVIRONMENTAL SCIENTISTS & GEOLOGISTS 6 ENGINEERS 1673 Main Street-P.O.Box 1743, Brewster,MA 02631 A 508-896.1706 Fax 508-896-5109 wwiw.bennett-ea.com F�,71 BEA09-10146 October 23,2013 [Rev 12/2/131 .. Mr. &Mrs.Randy Cox P.O.Box 604 Imperial,NE 69033 Via email:RandyCox2009@yahoo.com RE: OPERATION AND MAINTENANCE CONTRACT 2014 and 2015 Innovative/Alternative Wastewater Treatment System:OMNI RSF Unit 195-B Herring Run Place—Marston Mills,MA Dear Mr. and Mrs. Cox, BENNETT ENVIRONMENTAL ASSOCIATES,INC.(BEA)is pleased to provide you with a budget estimate for the.continuation of professional services relative to the operation and maintenance of the Innovative/Alternative Wastewater Treatment System located at the above referenced property. The semi-annual inspection and annual collection of samples from the effluent of the septic treatment system is a required condition of the system,as set forth by the Barnstable Health Department to qualify treatment capacity. As such, work proposed by BEA includes the standard operation and maintenance of the treatment system,as well as annual effluent sampling for total nitrogen,and the preparation of the required forms for distribution to the appropriate town and state offices. Additionally,at the time of such sampling,blowers,filters and associated piping will be inspected to assure working condition and regularly scheduled maintenance performed on a fixed cost basis will be invoiced semi-annually. Should any repair or treatment system components replacement be required,or additional sampling beyond the annual requirements be necessary,you will be notified to authorize the additional work and expenses. This work will be,billed at time and expense,portal to portal. Should field-testing parameters indicate the need to collect samples for laboratory analysis, such sampling will be conducted and will be noted on a BEA form that is left at your residence following the inspection. The following budget represents estimated annual costs through one year of service to include two inspections and a single sampling event. The annual costs are valid for two years (2014 and 2015)subsequent to the date of the first inspection scheduled for March 2014. Please note that this contract guns with the property. As such,it is your responsibility to notify our office in writing of any sale of the subject property so that there is no disruption of services. Furthermore, you are required to notify any buyer for the transfer of this contract. EMERGENCY SPILT.RESPONSE WASTE SITE CLEANUP Q SITE ASSESSMENT ® PERMITTING 6 SEPTIC DESIGN&INSPECTION WATER SUPPLY DEVELOPMENT,OPERATION&MAINTENANCE WASTEWATER TREATMENT,OPERATION&MAINTENANCE OGFOBER23,2013[Rev 12/2/13] PAGE 2 OF 2 UNIT 195B HERRING RUN PLACE,MARSTONS MILLS,MA SEMI-ANNUAL INSPECTION&MAINTENANCE/ANNUAL SAMPLING Inspect I/A system and take field measurements of dissolved oxygen, pH, and turbidity. Collect treated effluent wastewater samples on an annual basis under a proper chain-of-custody for MA certified laboratory analysis of nitrite/nitrate/TKN for total nitrogen. At the time of sampling events the conditions of the system will be inspected and documented with regards to the blower units,sludge level and associated piping. REPORTING/FILING Review inspection,field-testing,and laboratory analytical report relative to conditionalrequi ements ofthe system ender the MA DEP and local Board of Health approvals. Prepare DEP transmittal forms and submit inspection and sampling reports on the Barnstable County Department of Health and Environment online database on a semi-annual basis. Submit laboratory report and DEP transmittal forms to MA DEP,local Board ofHealth,and associated vendors/contractors,as appropriate,on an annual basis. Professional Services[March and September 2014] - $ 330.00 Professional Services[March and September 2015] $ 330.00 Laboratory Analysis[1x nitratelnitrite/TKN September 20141 $ 47.73 Laboratory Analysis[lx nitrate/nitrite/TKN September 2015] $ 47.73 Barnstable County Data Base Fee[20141 $ 50.00* Barnstable County Data Base Fee[2015] $ 50.00* *Noted:UA systems located in Barnstable County are required to report inspection and sampling results on the Mass Septic online database for use by the Barnstable County Department offlealth and Environment(BCDHE)and the local Boards of Health. At this time,BCDHE has found it necessary to institute annual user fees for filings on this required database of$50 per year. We are proceeding with the work as outlined. Immediate notification in writing is required if you do not wish to proceed. Otherwise, please sign the authorization below and return one copy of this proposal to our office. Should you have any questions or need additional information,please contact me directly at our office Very truly yours, BENNETT ENVIRONMENTAL ASSOCIATES,INC. Kara Risk Business Manager cc: Samantha Farrenkopf,Wastewater Program Coordinator encl. Terms&Conditions(2009)/Fee Schedule(2010) AUTHORIZATION: ,f "` J ,DATE: 0 ._ ��, �m^� _-``~-`.-~..�~ _�-`-- -`-_ ~ OMNURSF Operation and Maintenance Inspection Checklist r� A. |nstml|atloM & Smn«ice Information +° 8 FacilityStreet Address Date of Service city o»ommwummFirm System Startup Date Weather Co6ditions B. Septic Tank Sludge Pumping Required: Yes El No [] Sludge Depth: Scum Depth: Effluent tee filter: Yes Nu� If yes,inspect Fl&clean nd least yearly El If the sludge layer is within 12"of the outlet invert,recommend that the homeowner have the pumped,note the i tascumlayer thickness oo well.Also,inquire if the homeowner has a pumping schedule established with a licensed septage hauler,if not recommend a two to four year pumping schedule depending how heavily the system is used. 0 �����y��[�ti�n TwmW � F1 Check if-sludge accumulating Pumping required: YeoEl NoK] Odor problems: Yon[:1 NoP� If yes,description Effluent tee 0tec YoaE] No |f yes,inxpmct[]&clean at least yearly [] |f the sludge layer iagmater1han4rmquao that the homeowner pump outtho recirculationtynkinordor1n prevent clogging of the filter modules. Note the characteristics of the effluent coming out of the manifold this may indicate that the filter bed may need servicing. |t D. Equalization Tank(if installed) Sludge Pumping Required: Yes[I No[] []Sludge Depth: E]SoumDopth: Effluent tee filter: Yes NuF] |f yes,inspect El&clean ut least yearly n Same inspection criteria uo septic tank: E, Pump Chamber/Vault(if Installed) Q]pump|nopoo�uno�Nun�� If problems,describe _A Float ^� ` Check all"""=~"for operation Make Sure the pump is operational by pulling up the float switch;if the pump io not operational immediate corrective actions need tobotaken. i F. Pumps, Switches, Floats, Alarm System t � (Pump Inspections(all units) � If problems,describe � /❑Test pump alternator,or record hours 11,• Hours of operation [ ] Float switches I Check all switches for operation -Test alarm If non-functioning,corrective action(s) Make sure pump(s), Float(s)and audible alarms)are functional,if not make a note so that corrective actions can be made. G. Filter Modules ("Sand Filters") h-1 f�flnspect for ponding Ponding Present:Yes❑ WD (;Clean bed: Yes❑ No Distribution pipes Flush:Yes❑ No,,C]' Brush: Yes❑ Nof] 7"•Any obstruction of airflow to filter modules: Yes❑ No Fv1"If Yes,explain below(i.e.snow,dirt) To inspect the condition of the filter modules remove the mulch layer at one corner of the filter module area, then lift the filter fabric so that the media can be inspected through the end of the contactor. The media should have a thin biomass layer growing on it and should have a brownish shaggy coloration.If the surface of the filter module area appears to be clogged,or the biomass layer is too think it is suggested to completely expose the filter modules,and rake the filter beds thoroughly,then wash the filter beds down with a garden hose(with a pressure nozzle on it).Then Recover the filter beds as they were found. H. Sample Collection Yes ..i; No❑ ,{ If yes: ❑ ❑BOD TSS ❑ �I pH RITN I Other All samples are to be taken from the manifold located in the recirculation tank,and are to be stored in sterile, laboratory supplied containers.In order to prevent any cross-contamination from a previous sample rinse the dip cup into the effluent stream at the manifold three times so that a representative sample can be obtained. Make sure to wear proper safety equipment while pulling samples(i.e.rubber gloves). System Notes: rec-i IV, rci v�"���4�E'Et.�S br•t e�E^i}.° :+. .-'�;R���`::,t{�'S�?;� ��. 'C:t�>," x�"<s l'f';_,.^r �%�.8'�3�'3��y`C=F'�,. f f: • t� �'_ �VS-�°�'► �✓�'•� �(t�{�, *��r-o�•e,�''= c�.:'t 'It')'/'cfr �%L�� �t)��,r�t� (���'�� -bENNETTENviRoNmENTAL ssocums9INC. ci��V� 1573 Main St.,P.O.Box 1743 Brewster,MA 02631 I•_L 508-896-1706 a www.beiinett-ea.com Date&time of visit: A site visit was conducted today for: O&M '[ (YES ❑ NO Testing I(YES ❑ NO Repair ❑YES K NO Alarm Call ❑YES Q NO Your system is operating correctly P YES ❑ NO Tanks) in need of pumping ❑YES NO .Further maintenance required ❑YES [ NO Repairs needed Cl YES 15NO Please contact our office ❑YES ;:g,. O Contract renewal required ❑YES `;6 N0 Field testing -IPIPass '❑ Fail Sample pulled DYES ❑ NO Laboratory sampling conducted 0-YES '❑ NO a BENtJETT.EfJVIRONMENI. TAL,`:�`;;: ;;G1pClgl'ES,INC. . A$S WMENT @^,r` R E$OUflCE.MANAGEMEIJT�:`« s" - Serial No:09111519:49 HA ANALYTICAL r-� ANALYTICAL REPORT Lab Number: L1522077 Client: Bennett Environmental Associates 1573 Main Street Brewster, MA 02631 ATTN: David Bennett Phone: (508)896-1706 Project Name: COX RESIDENCE Project Number: BEA09-10146 Report Date: 09/11/15 The original project report/data package is held by Alpha Analytical.This report/data package is paginated and should be reproduced only in its entirety.Alpha Analytical holds no responsibility for results and/or data that are not consistent with the original. Certifications&Approvals: MA(M-MA086),NY (11148),CT(PH-0574),NH(2003),NJ NELAP(MA935),RI(LA000065),ME(MA00086), PA(68-03671),VA(460195),MD(348),IL(200077),NC(666),TX(T104704476),DOD(1-2217),USDA(Permit #P-330-11-00240). Eight Walkup Drive, Westborough, MA 01581-1019 508-898-9220 (Fax)508-898-9193 800-624-9220-www.alphalab.com Page 1 of 15 Serial No:09111519:49 Project Name: COX RESIDENCE Lab Number: L1522077 Project Number: BEA09-10146 Report Date: 09/11/15 Alpha Sample Collection Sample ID Client ID Matrix Location Date/Time Receive Date L1522077-01 EFFLUENT WATER MARSTONS MILLS, MA 09/09/15 08:20 09/09/15 Page 2 of 15 c�, Serial No:09111519:49 Project Name: COX RESIDENCE Lab Number: L1522077 Project Number: BEA09-10146 Report Date: 09/11/15 Case Narrative The samples were received in accordance with the Chain of Custody and no significant deviations were encountered during the preparation or analysis unless otherwise noted.Sample Receipt,Container Information,and the Chain of Custody are located at the back of the report. Results contained within this report relate only to the samples submitted under this Alpha Lab Number and meet all of the requirements of NELAC,for all NELAC accredited parameters.The data presented in this report is organized by parameter(i.e.VOC,SVOC,etc.).Sample rNn 1`0 specific Quality Control data(i.e.Surrogate Spike Recovery)is reported at the end of the target analyte list for each individual sample, followed by the Laboratory Batch Quality Control at the end of each parameter.Tentatively Identified Compounds(TICs),if requested,are reported for compounds identified to be present and are not part of the method/program Target Compound List,even if only a subset of the TCL are being reported.If a sample was re-analyzed or re-extracted due to a required quality control corrective action and if both sets of data are reported,the Laboratory ID of the re-analysis or re-extraction is designated with an"R"or"RE",respectively.When multiple Batch Quality Control elements are reported(e.g.more than one LCS),the associated samples for each element are noted in the grey shaded header line of each data table.Any Laboratory Batch,Sample Specific%recovery or RPD value that is outside the listed Acceptance Criteria is bolded in the report.All specific QC information is also incorporated in the Data Usability format of our Data Merger tool where it can be reviewed along with any associated usability implications.Soil/sediments,solids and tissues are reported on a dry weight basis unless otherwise noted.Definitions of all data qualifiers and acronyms used in this report are provided in the Glossary located at the back of the report. In reference to questions H(CAM)or 4(RCP)when"NO"is checked,the performance criteria for CAM and RCP methods allow for some quality control failures to occur and still be within method compliance. In these instances the specific failure is not narrated but noted in the associated QC table.The information is also incorporated in the Data Usability format of our Data Merger tool where it can be reviewed along with any associated usability implications. Please see the associated ADEx data file for a comparison of laboratory reporting limits that were achieved with the regulatory Numerical Standards requested on the Chain of Custody. HOLD POLICY For samples submitted on hold,Alpha's policy is to hold samples(with the exception of Air canisters)free of charge for 21 calendar days from the date the project is completed.After 21 calendar days,we will dispose of all samples submitted including those put on hold unless you have contacted your Client Service Representative and made arrangements for Alpha to continue to hold the samples.Air canisters will be disposed after 3 business days from the date the project is completed. Please contact Client Services at 800-624-9220 with any questions. I, the undersigned,attest under the pains and penalties of perjury that,to the best of my knowledge and belief and based upon my personal inquiry of those responsible for providing the information contained in this analytical report, such information is accurate and complete. This certificate of analysis is not complete unless this page accompanies any and all pages of this report. ( � Kelly Stenstrom Authorized Signature: Title: Technical.Director/Representative Date: 09/11/15 A Page 3 of 15 =-- Serial No:09111519:49 Nrn Oma AN K".#S WSCELLANEOUS Page 4 of 15 Serial No:09111519:49 Project Name: COX RESIDENCE Lab Number: L1522077 Project Number: BEA09-10146 Report Date: 09/11/15 SAMPLE RESULTS 'd Lab ID: L1522077-01 Date Collected: 09/09/15 08,20 Client ID: EFFLUENT Date Received: 09/09/15 raw Sample Location: MARSTONS MILLS,MA Field Prep: Not SpecifiErI Matrix: Water M=' rti�= Dilution Date Date Analyticalr%-- Parameter Result Qualifier Units RL MDL Factor Prepared Analyzed Method Analyst General Chemistry-Westborough Lab Nitrogen,Nitrite 0.24 mg/I 0.050 1 09/09/15 23:22 44,353.2 MR Nitrogen,Nitrate 4.1 mg/I 0.10 1 09/09/15 23:22 44,353.2 MR Nitrogen,Total Kjeldahl 2.11 mg/I 0.300 1 09/10/15 07:32 09/10/15 21:38 30,4500N-C AT K.\ r �. Page 5 of 15 Serial No:09111519:49 Project Name: COX RESIDENCE Lab Number: L1522077 Project Number: BEA09-10146 Report Date: 09/11/15 Method Blank Analysis Batch Quality Control Dilution Date Date Analytical Parameter Result Qualifier Units RL MDL Factor Prepared Analyzed Method Analyst General Chemistry-Westborough Lab for sample(s): 01 Batch: WG819812-1 Nitrogen,Nitrate ND mg/1 0.10 1 09/09/15 22:37 44,353.2 MR General Chemistry Westborough Lab for sample(s): 01 Batch: WG819814-1 Nitrogen,Nitrite ND mg/I 0.050 1 - 09/09/15 22:46 44,353.2 MR General Chemistry-Westborough Lab for sample(s): 01 Batch: WG819931-1 Nitrogen,Total Kjeldahl ND mg/I 0.300 1_ 09/10/15 07:32 09/10/15 21:34 30,4500N-C AT AIL?HA Page 6 of 15 Serial No:09111519:49 Lab Control Sample Analyses Project Name: COX RESIDENCE Batch Quality Control Lab Number: L1522077 Project Number: BEA09-10146 Report Date: 09/11/15 LCS LCSD %Recovery Parameter %Recovery Qual %Recovery Qual Limits RPD Qua[ RPD Limits General Chemistry ,,Westborough Lab .Associated sample(s): 01 Batch: WG819812-2 Nitrogen,Nitrate 96- 90-110 General Chemistry-=Westborough Lab Associated sample(s): 01 Batch:WG819814-2 Nitrogen,Nitrite 102 90-110 20 General Chemistry-Westborough Lab Associated sample(s): 01 Batch:WG819931-2 Nitrogen,Total Kjeldahl 101 78-122 '7; A,3, r Page 7 of 15 :j�,`�. /'ALPHA Serial No:09111519:49 Matrix Spike Analysis Project Name: COX RESIDENCE Batch Quality Control Lab Number: L1522077 Project Number: BEA09-10146 Report Date: 09/11/15 Native MS MS MS MSD IVISD Recovery RPD Parameter Sample Added Found %Recovery Qual Found %Recovery Qual Limits RPD Qual Limits General Chemistry-Westborough Lab Associated sample(s): 01 QC Batch ID: WG819812-4 QC Sample: L1522039-01 Client ID: MS Sample Nitrogen, Nitrate 3.4 4 7.0 90 - 83-113 6 General Chemistry-Westborough Lab Associated sample(s): 01 QC Batch ID: WG819814-6 QC Sample: L1522039-01 -Client ID: MS Sample Nitrogen,Nitrite 0.84 4 4.9 102 80-120 - 20 General Chemistry-Westborough Lab Associated sample(s): 01 QC Batch ID: WG819931-4 QC Sample: L1522044-03 Client ID: MS Sample Nitrogen,Total Kjeldahl 0.418 8 7.88 93 77-111 24 Page 8 of 15 / %�tia Serial No:09111519:49 Lab Duplicate Analysis Project Name: COX RESIDENCE Batch Quality Control Lab Number: L1522077 Project Number: BEA09-10146 Report Date: 09/11/15 Parameter Native Sample Duplicate Sample Units RPD Qual RPD Limits General Chemistry-Westborough Lab _Associated sample(s): 01 QC Batch ID: WG819812-3 QC Sample: L1522039-01 Client ID: DUP Sample _ Nitrogen,Nitrate 3.4 3.4 mg/I 0 6 General Chemistry-Westborough Lab Associated sample(s): 01 QC Batch ID: WG819814-5 QC Sample: L1522039-01 Client ID: DUP Sample Nitrogen,Nitrite 0.84 0.84 mg/1 0 20 General Chemistry-Westborough Lab Associated sample(s): 01 QC Batch ID: WG819931-3 QC Sample: L1522044-03 Client ID: DUP Sample Nitrogen,Total Kjeldahl 0.418 0.432 mg/I 3 24 Page 9 of 15 � ?HA Serial No:09111519:49 Project Name: COX RESIDENCE Lab plumber: L1522077 Project Number: BEA09-10146 Report Date: 09/11/15 Sample Receipt and Container Information Were project specific reporting limits specified? YES Reagent H2O Preserved Vials Frozen on: NA Cooler Information Custody Seal Cooler A Absent Container Information Temp Container ID Container Type Cooler pH deg C Pres Seal Analysis(*) L1522077-01A Plastic 250ml H2SO4 preserved A <2 3.2 Y Absent TKN-4500(28) L1522077-01B Plastic 250mlunpreserved A 7 3.2 Y Absent NO2-353(2),NO3-353(2) *Values in parentheses indicate holding time in days Page 10 of 15 ._ ,..r.�. i Serial No:09111519:49. Project Name: COX RESIDENCE Lab Number: L1522077 Project Number: BEA09-10146 Report Date: 09/11/15 GLOSSARY �W Acronyms `w EDL Estimated Detection Limit:This value represents the level to which target analyte concentrations are reported as estimated '° values,when those target analyte concentrations are quantified below the reporting limit(RL).The EDL includes any adjustments from dilutions,concentrations or moisture content,where applicable.The use of EDLs is specific to the analysis of PAHs rising Solid-Phase Microextraction(SPME). 41 EPA Environmental Protection Agency. LCS Laboratory Control Sample:A sample matrix,free from the analytes of interest,spiked with verified known amounts of analytes or a material containing known and verified amounts of analytes. Iw 7 LCSD Laboratory Control Sample Duplicate:Refer to LCS. LFB Laboratory Fortified Blank:A sample matrix,free from the analytes of interest,spiked with verified known amounts of analytes or a material containing known and verified amounts of analytes. MDL Method Detection Limit:This value represents the level to which target analyte concentrations are reported as estimated values, when those target analyte concentrations are quantified below the reporting limit(RL).The MDL includes any adjustments from dilutions,concentrations or moisture content,where applicable. MS Matrix Spike Sample:A sample prepared by adding a known mass of target analyte to a specified amount of matrix sample for which an independent estimate of target analyte concentration is available. MSD Matrix Spike Sample Duplicate:Refer to MS. NA Not Applicable. NC Not Calculated: Term is utilized when one or more of the results,utilized in the calculation are non-detect at the parameter's reporting unit. NI Not Ignitable. NP Non-Plastic:Term is utilized for the analysis of Atterberg Limits in soil. RL Reporting Limit: The value at which an instrument can accurately measure an analyte at a specific concentration.The RL includes any adjustments from dilutions,concentrations or moisture content,where applicable. RPD Relative Percent Difference: The results from matrix and/or matrix spike duplicates are primarily designed to assess the precision of analytical results in a given matrix and are expressed as relative percent difference(RPD). Values which are less than five times the reporting limit for any individual parameter are evaluated by utilizing the absolute difference between the values; although the RPD value will be provided in the report. SRM Standard Reference Material:A reference sample of a known or certified value that is of the same or similar matrix as the associated field samples. TIC Tentatively Identified Compound:A compound that has been identified to be present and is not part of the target compound list (TCL)for the method and/or program.All TICS are qualitatively identified and reported as estimated concentrations. Footnotes 1 The reference for this analyte should be considered modified since this analyte is absent from the target analyte list of the original method. Terms Total:With respect to Organic analyses,a'Total'result is defined as the summation of results for individual isomers or Aroclors.If a'Total' result is requested,the results of its individual components will also be reported.This is applicable to'Total'results for methods 8260,8081 and 8082. Analytical Method:Both the document from which the method originates and the analytical reference method.(Example:EPA 8260B is shown as 1,8260B.)The codes for the reference method documents are provided in the References section of the Addendum. Data Qualifiers A Spectra identified as"Aldol Condensation Product". B The analyte was detected above the reporting limit in the associated method blank.Flag only applies to associated field samples that have detectable concentrations of the analyte at less than ten times(1 Ox)the concentration found in the blank.For MCP-related projects,flag only applies to associated field samples that have detectable concentrations of the analyte at less than ten times(IOx) the concentration found in the blank.For DOD-related projects,flag only applies to associated field samples that have detectable concentrations of the analyte at less than ten times(1 Ox)the concentration found in the blank AND the analyte was detected above one-half the reporting limit(or above the reporting limit for common lab contaminants)in the associated method blank.For NJ- Air-related projects,flag only applies to associated field samples that have detectable concentrations of the analyte above the reporting limit.For NJ-related projects(excluding Air),flag only applies to associated field samples that have detectable concentrations of the analyte,which was detected above the reporting limit in the associated method blank or above five times the reporting limit for common lab contaminants(Phthalates,Acetone,Methylene Chloride,2-Butanone). C Co-elution:The target analyte co-elutes with a known lab standard(i.e.surrogate,internal standards,etc.)for co-extracted analyses. Report Format: Data Usability Report ikPHA Page 11 of 15 Serial No:09111519:49 Project Name: COX RESIDENCE Lab Number: L1522077 Project Number: BEA09-10146 Report Date: 09/11/15 Data Qualifiers D Concentration of analyte was quantified from diluted analysis.Flag only applies to field samples that have detectable concentrations of the analyte. E Concentration of analyte exceeds the range of the calibration curve and/or linear range of the instrument. G The concentration may be biased high due to matrix interferences(i.e,co-elution)with non-target compound(s).The result should be considered estimated. H The analysis of pH was performed beyond the regulatory-required holding time of 15 minutes from the time of sample collection. I The lower value for the two columns has been reported due to obvious interference. M Reporting Limit(RL)exceeds the MCP CAM Reporting Limit for this analyte. NJ Presumptive evidence of compound.This represents an estimated concentration for Tentatively Identified Compounds(TICS),where the identification is based on a mass spectral library search. P The RPD between the results for the two columns exceeds the method-specified criteria. Q The quality control sample exceeds the associated acceptance criteria.For DOD-related projects,LCS and/or Continuing Calibration Standard exceedences are also qualified on all associated sample results. Note:This flag is not applicable for matrix spike recoveries when the sample concentration is greater than 4x the spike added or for batch duplicate RPD when the sample concentrations are less than 5x the RL.(Metals only.) R Analytical results are from sample re-analysis. RE Analytical results are from sample re-extraction. S Analytical results are from modified screening analysis. J Estimated value.This represents an estimated concentration for Tentatively Identified Compounds(TICS). ND Not detected at the reporting limit(RL)for the sample. Report Format. Data Usability Report )5 ALPHA Page 12 of 15 Serial No:09111519:49 Project Name: COX RESIDENCE Lab Number: L1522077 Project Number: BEA09-10146 Report Date: 09/11/15 REFERENCES x I"7 30 Standard Methods for the Examination of Water and Wastewater.APHA-AWWA- w WPCF. 18th Edition. 1992. 44 Methods for the Determination of Inorganic Substances in Environmental Samples, EPA/600/R-93/100,August 1993. f'ti.5 LIMITATION OF LIABILITIES Alpha Analytical performs services with reasonable care and diligence normal to the analytical testing laboratory industry. In the event of an error,the sole and exclusive responsibility of Alpha Analytical shall be to re-perform the work at it's own expense. In no event shall Alpha Analytical be held liable for any incidental, consequential or special damages, including but not limited to, damages in any way connected with the use of, interpretation of, information or analysis provided by Alpha Analytical. We strongly urge our clients to comply with EPA protocol regarding sample volume, preservation, cooling, containers, sampling procedures, holding time and splitting of samples in the field. Page 13 of 15 Serial No:09111519:49 Certification Information Last revised December 16,2014 The following analytes are not included in our NELAP Scope of Accreditation: Westborough Facility EPA 524.2:Acetone, 2-Butanone (Methyl ethyl ketone(MEK)), Tert-butyl alcohol, 2-Hexanone,Tetrahydrofuran, 1,3,5-Trichlorobenzene, 4-Methyl-2-pentanone (MIBK), Carbon disulfide, Diethyl ether. EPA 8260C: 1,2,4,5-Tetramethylbenzene,4-Ethyltoluene, lodomethane (methyl iodide), Methyl methacrylate, Azobenzene. EPA 8270D: 1-Methylnaphthalene, Dimethyl naphtha lene,1,4-Diphenylhydrazine. EPA 625: 4-Chloroaniline,4-Methylphenol. SM4500: Soil: Total Phosphorus, TKN, NO2, NO3. EPA 9071: Total Petroleum Hydrocarbons, Oil & Grease. Mansfield Facility EPA 8270D: Biphenyl. EPA 2540D: TSS EPA TO-15: Halothane, 2,4,4-Trimethyl-2-pentene, 2,4,4-Trimethyl-1-pentene, Thiophene, 2-Methylthiophene, 3-Methylthiophene, 2-Ethylthiophene, 1,2,3-Trimethyl benzene, Indan, Ind.ene, 1,2,4,5-Tetramethylbenzene, Benzothiophene, 1-Methylnaphthalene. The following analytes are included in our Massachusetts DEP Scope of Accreditation,Westborough Facility: Drinking Water EPA 200.8: Sb,As,Ba,Be,Cd,Cr,Cu,Pb,Ni,Se,TI; EPA 200.7: Ba,Be,Ca,Cd,Cr,Cu,Na; EPA 245.1: Mercury; EPA 300.0: Nitrate-N, Fluoride, Sulfate; EPA 353.2: Nitrate-N, Nitrite-N; SM4500NO3-F: Nitrate-N, Nitrite-N; SM4500E-C, SM4500CN-CE, EPA 180.1, SM213013, SM4500CI-D,SM232013, SM2540C, SM4500.H-B EPA 332: Perchlorate. Microbiology: SM921513; SM9223-P/A, SM9223B-Colilert-QT, Enterolert-QT. Non-Potable Water EPA 200.8:AI,Sb,As,Be,Cd,Cr,Cu,Pb,Mn,Ni,Se,Ag,TI,Zn; EPA 200.7:AI,Sb,As,Be,Cd,Ca,Cr,Co,Cu,Fe,Pb,Mg,Mn,Mo,Ni,K,Se,Ag,Na,Sr,Ti,TI,V,Zn; EPA 245.1, SM4500H,6, EPA 120.1, SM251013, SM2540C, SM234013, SM232013, SM4500CL-E,SM4500E-BC, SM426C, SM4500NH3-BH, EPA 350.1:Ammonia-N, LACHAT 10-107-06-1-B:Ammonia-N, SM4500NO3-F, EPA 353.2: Nitrate-N, SM4500NH3-BC-NES, EPA 351.1, SM4500P-E, SM4500P-B, E, SM522013, EPA 410.4, SM521013, SM5310C, SM4500CL-D, EPA 1664, SM14 510AC, EPA 420.1,SM4500-CN-CE, SM254013. EPA 624: Volatile Halocarbons&Aromatics, EPA 608: Chlordane, Toxaphene,Aldrin, alpha-BHC, beta-BHC, gamma-BHC, delta-BHC, Dieldrin, DDD, DDE, DDT, Endosulfan I, Endosulfan II, Endosulfan sulfate, Endrin, Endrin Aldehyde, Heptachlor, Heptachlor Epoxide, PCBs EPA 625: SVOC (Acid/Base/Neutral Extractables), EPA 600/4-81-045: PCB-Oil. Microbiology: SM9223B-Colilert-QT; Enterolert-QT,SM9222D-MF. For a complete listing of analytes and methods, please contact your Alpha Project Manager. Page 14 of 15 Serial No:09111519:49 1 HAN OF CUSTODY PAGE 1 OF 1 Date Re Cd if)Lab, l�t � ALPHAJob##: "'PH GIJ07 —_ _ -" ❑ FAX ® EMAIL ®Same as Client info PO#:10146 Westborough,MA Mansfield,MA Project Name:Cox Residence TEL:508-898-9220. TEL:508-822-9300 ❑ ADEx ❑ Add']Deliverables FAX 508.898-9193 FAX:508-822-3288 • = • Project Location:Marstons Mills;MA State/Fed Program criteria Client:Bennett Environmental Associates Project#:BEA09-10146 Address: 1573 Main Street/P.O.Box 1743 Project Manager:David C.Bennett 4,1 Brewster,MA 02631 ALPHA Quote#: Phone:508-896-1706 I o e s ANALYSIS e,. Fax:508-896-5109 ®Standard ❑ Rush(ONLY IF PRE-APPROVED) SAMPLE HANDLING Email:sfarrenkopf@bennett-ea.com Filtration ❑ Done ❑These samples have been Previously analyzed by Alpha Due Date: Time: ® Not Needed Other Project Specific Requirements/Comments/Detection Limits: Labtoao Preservation ❑ Lab to do (Please specify Y:q below) N ALPHA Lab ID Sample ID Collection Sample Samplers z (Lob Use Only) Date Time Matrix Initials m z Sample Specific Comments Effluent Q ( �'rZ� W1N 6l 43 ® ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 2.. ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑. ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 10 ❑ o Container Type P P - - - - - - 0 D Please print clearly,Ngibly Preservative and completely. Samplescan not be!ogged to and /R`Iinqulshed By: Daterrime Received By: Date/Time urnarumid tune clock will not f , / start until any ambiautlws are 2 v �/l CL C� , +�A` : / - resuNcd. All samples submilt=d are sublert to (rer.2&nPROe) FORMi-ARR4etQ Alpha's R:iyment Tetms. Page 15 of 15 3 it _ f Qf -4r f a:- 1 r 31TEM', & OAINI 2000.- , RECIRCULATtNTG ' SAND FILTER PROFILE - & � DkTAILS NOT i O SCALE AND 'COVERS TO WITHIN 6" OF FINISH. GRADE tlj"" INE 'BARI� MU Cii' ' OMNI 2000 RE —CI€2CULATING- SAND FILTER 2 MODULES REQUIRED FILTER FABRIC COVER (NO SUBSTITUTION) AIRATION HOODS VERS TO GRADE 1.5" PRESSURIZED LINE IC 56.0 �' _._ .. 3' PVC RETURN LINE. 55.9 Tbt OF 3 RECIRC: R.S.F. FINISH GRADE 53.5�-55.5 TANK= 56.0 — ��E 2A' 1Yp, a 511:, A M ULE _. ..... ,.T' I T t 1 {- AC74 r 3 PEAST.ONt t , V1� r `G/ w • 1 1 J2 P •• II 50 85 OAS 1 52.2_ _ d a . e j` d 'A 6 RE ` a HIGH YJATEFt' ALLOW` 3 4 T 1 1 �:: r x •- t - r {. S STO S{E : r_ - _ w WA SHE TANk_ �_ ,_ _._� _ = _ z- -- -_ r_ ,_ _-- _ __ -�_ . ,__ , a, - - , _..� OFF 1 — _ _ L AT--R S U� I �,�_-�,._�: , m PUMP - . , •� --,� �._; - ---- __�_ �_ _: _,---- OW W E H. T, OFF r -- — -- - - _• - - IL :4 - -. , 1000 GALLON# OMNI. 2.000 _. _ _ — _ r F —11 _ 1+=mrl � _ _ r� ., .,, _ _ —,• .. ,., �it r.;l -�II -- .1� -- LPL RECLRCULAr QN T N e Tl A K c F�ILTE s G „ s _ , _ B iO i w 120.04 PUM,f? .CHAMBER orr M E , OMN w : ': ; ! K -, r_ OrL,:. ro sr !I�r (,N(7- SUE3STITUTION,), ,.� s ' 3 r, 5Q GAL.PUMP. CNAM•,8E e.. Al,,- � c - r ti.� - ,M F, � _ __ _ � t �,.I�`SI�N«E,�ti '�� c, t ...,. ,. 'v `.-� i.... �..:i - _ i ,`• .,q +j« Sn.:R 0 -.+, .fy-s OX.:TIMER AN'C EV�N,T-C, , R: „ N QUNTE f r h o _ _ _�•. = , VA L�lE u . : ,F 'r w r SH:OULb RE MONITORED FRbM r ! . ti t r a M y _ 4 ' . .. - , ��. .�� , P UC ATE A CONTROL ANEL - _ I - $# ' �A L. �/� w�r� w�IvE �� A.. 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YOU CAN BECOM AT THE TIME OF INSTALLATION. PLEASE Q OMNI AT 1-888-450-OMNI FOR DETAIL" H , 00 F r W PLAN VIEW o EG .N D PROPLEGEND SCALE: 1"= 20' ELEV. = X60..5 EXIST. SPOT ELEV. = x56.04 PROP. CONTOUR The site is situated in Flood Zone "C" = 46 � � . EXIST. CONTOUR = _��q 6 ASSESSORS MAP #78 LOT 18 ';Title• V see ic tank C:11 WA i , i F . ' 140.8 if .x 2' x 0.74 108.38 g.p.d. 55�'4{ I x B L S *` tr <.�;!. ,�. , ;. � , {: i ;.r ,:!, •r ,;.! ,, a r t{':; ;+ ,: _ ; + .. ; 338.25 -. •.;• �rg�P.d./0.74 , r 457.1 s.`. �� GENERAL NOTLS 50 -"3'2'. C M/S s 1. ALL ELEVATIONS SHOWN ARE ~ ASSUMED. 46.9 , 2. ALL PIPES IN .THE SYSTEM TO BE 56.3 DEEP OBSERVATION HOLE- #F-2 CAST IRON OR SCHEDULE 40 P.V.C. 1; i - 3. REMOVE'ALL UNSUITABLE MATERIAL b���go, A. S/L BENEATH THE•INVERT ELEVATION FOR A RAYiUS OF 5' AS PER 310CMR 15.255(5) 55.6s— 53.8 . 8 -30 i ' ` AND BACICFILL W/ CLEAN COARSEB L/S GRANULAR MATERIAL. .4. ALL 13ACKFILL SHALL BE CLEAN ' COARSE GRANULAR MATERIAL FREE 30"�132" C M/S FROM DEBRIS & LARGE STONBS. 5. CHRISTOPHER COSTA & Assoc. 45.3 . MUST BE NOTIFIED WHEN THE SYSTEM IS INSTALLED PRIOR TO PERCOLATION RATE _ <5 MIN./INCH BACKFILUNG FOR INSPECTION, j DEPTH TO GROUNDWATER = NONE ENCOUNTER'-' 6. UNLESS OTHERWISE NOTED ALL p ) Ci;SEF:�,'ATIONS BY: JERRY DUNNING SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE WITH BRUCE, G. MURPHY MASSACF-iUSETTS TITLE V SANITARY ��H of TAKEN 8Y: :3/24/98 SEWER CODE,AND LOCAL RULES ctAs DATE tESIED: ' WHICH MAY bE APPLICABLE IN A sCHNEIOER WORKMAN—LIKE MANNER. Q CML NM 3W40 7. THIS LOT IS NOT IN THE FLOOD PLAIN. 8. A GARBAGE GRINDER WILL NOt BE: INSTALLED' ON THE SYSTEM. 9. NO CHANGES SHALL BE MADE TO THIS PLAN WITHOUT PRIOR APPROVAL FROM CHRISTOPHER COSTA & ASSOC. ` 10. DIG—SAFE SHALL BE NOTIFIED FOR THE PROPER / APPLICANT: BAYSIDE BUILDING CO., INC, LOCATION OF EXISTING UTILITIES PRIOR TO ANY OF.M DWELLI LT PROPOSED G LOCATION EXCAVATION. ��' gssp 1V 11. OMNI 2000 PRODUCTS AVAILABLE THROUGH z � OMNI ENVIRONMENTAL SYSTEMS Al' 1-888-450—OMNI � CH CIOSOA ER 1 O ' PROPOSED SET4TAE� SYSTEM LOCATION 12. OMNI 2000 CONTROL PANEL TO 3E LOCATED No. 31305 INSIDE DWELLING IN A VISIBLE &. AUD18LE LOCATION. • .SOT .1 � U NIT 1 RO UTE 14, 14. ONLY OMNI 2000 g10"FILTER COMPONENTS N N NO SUBSTITUTIONS s REVISIONS 12 a OL. BARNS TABLE (MaR .!rorrs AOLL.5), .MASSACHUSET 2 SCALE: AS NOTED DATE: 9/12/02 C'RT/F/E`D PLOT PLAN & TOPOGRAPHY DRAWN BY: JAB . CHECKED BY: C.C: JOB NO.: DONE D Y. _ CHRISTOPI ER COSTA & assoc. .�E,S'.I .1V� P.O. BOX 128/.465 ' L.• PALMOUTH HWY. _ N0. DATE DESCRIP710N BY LAST FALMOUTH MASSACHUSETTS :.. .r , •s + - ..r�: ;r ,�i :i r i �i M ! {i 1 >r ,.15 .., nr. y: ,j. i PI<:, a .. - - ;. . - .. 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