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1049 MAIN ST./RTE 6A(W.BARN.) - Health
1049 MA.N ST./RT.GA,W.BAR-NSTABLE - A=178.030 F TOWN OF BARNSTABLE G e< .f LOCATION lD�l `6 Teel/ 6�7 • SEWAGE # VILLAGE w 14d/�'�15Az1/® ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. lef*4911; CdesT 7 SEPTIC TANK CAPACITY CooOGyL // LEACHING FACILITY: (type) r00 6 Z"4 9,J (size) 1A.Jr X Af'X-? NO.OF BEDROOMS / BUILDER O OWNE PERMITDATE: ''�`�� COMPLIANCE DATE: -1.' Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility {S� 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 IQCR�' lye c r .R No. 9T-710 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Ztgozal *p5tem Congtruction Permit Application for a Permit to Construct( )Repair(i/)Upgrade( )Abandon( ) El Complete System ®Individual Components Location Address or Lot No. ®0`7 �yn Dy/� Owner's Name,Address and Tel.No. Assessor's Map/Parcel qg jy de,?& 5R/ AWIOA�Ihhll dvlvm�e_116 Installer's Name,A dress,and Tel.No. Designer's Name,Address and Tel.No. Name, 40^7--- /n Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( � Other Type of Building 40 /G No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /�% /7 gallons per day. Calculated daily flow 3 301 gallons. Plan Date Number of sheets Revision Date Title �. Size of Septic Tank g2,9,> 410 Type of S.A.S. /Z•t '7f_ Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7-I Tle. �Qli^ 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 place the system in operation until a Certifi- cate of Compliance has been issued hy this B d f Health. / Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. fry ��� Date Issued if a— 9 No. / 6 Z I 0 Fee �r / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ` Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Zipprication for Woopt *pgtem Coward'ction Permit Application for a Permit to Construct( )Repair(V/)Upgrade( )Abandon( ) O Complete System /Individual Components Location Address or Lot No. f levl N.I# $ � pw Owner's Name,Address and Tel.No. Assessor's Map/Parcel °7 7 v! /� J-ei# 40R�✓r' c� ���rh 7`A'di� Installer's Name,A dress, -and /Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms_J� Lot Size sq.ft. Garbage Grinder(_1�0 Other Type of Building 101) /G e No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Z/ gallons per day. Calculated daily flow 3 3e gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank AA00 �Xls?`/a9 Type of S.A.S. _/2, 1 Description of Soil v Nature of Repairs or Alterations(Answer when applicable) 7�7liPi�P//^ �ry 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 place the system in operation until a Certifi- : cate of Compliance has been issued by this Board f Health. Signed Date A Application Approved by Date y01 Application Disapproved for',the following reasons 5 Permit No. Al Date Issued THE COMMONWEALTH OF MASSACHUSETTS / 7 eo34 �. BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, thj;t the On-site Sewage Disposal System Constructed( )Repaired ( ✓Upgraded( ) Abandoned( )by O CB / at / has been constructed in accorduance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9. Z /0 dated Installer Designer The issuance of this, �ermit shall no te construed as a guarantee that the system w ll function as designed. Date '7 ` a 1 Inspector Cy —/ Fee re THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 1=i.5pogal *pgtem Construction Permit Permission is hereby granted to Construct( )Repair(VI)Upgrade( )Abandon System located at ld/f 1 A4 /LIQI e 6; W ,6e, s/-o g le and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this pemit. Date: y�' —�� Approved by IR TOWN OF BARNSTABLE LOCA TION /d % T SEWAGE S� VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 0 4 C./,(b LEACHING FACMITY: (type) (size) G X s NO. OF BEDROOMS L/) BUILDER OR OWNER PERMIT DATE: 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 l i on site or within 200 feet of leaching facility) / J y Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by�� i 1 d ,ona a3 r 10liq TOWN OF BARNSTABLE LOCAnON'44A ANN 11, SEWAGE # VILLAGE W 2 6147 1J rA'13 4.4� ASSESSOR'S MAP&LOTC 71R 4 40 INSTALLER'S NAME&PHONE NO. ItIM At6,eS7/Z 17 7 ev 0 I' SEPTIC TANK CAPACITY LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNER ._ PERMITDATE: ! ��8/�'l COMPLIANCE DATE: ?Z ` 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) �7 t� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facilit Feet Furnished by k/o lf� .t '0 ;y 3 53_- � 73 , q f TOWN OF BARNSTABLE Ee e, -LOCATION ID�l4 �G/4 //J1lI%1> �J`• SEWAGE # zl© j VU.LAGE �t1 75fA'�/� ASSESSOR'S MAP& LOT L?�03j INSTALLER'S NAME dt PHONE NO. kT 7��oJ�`> 61157: 7 71`?-W SEPTIC TANK CAPACITY 40004G LEACHING FACII.ITY: (type) jw gp ,ji; Lme< &,w J,,L(size)/R.f ,c,'tr.. a ' NO.OF BEDROOMS 1A BUR.DER 0:f/`Li�x� /lat'i Ll� oi+ta�sG PERb ATE: y`'y—f l COMPLIANCE DATE: y -1�, -Q 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S-0- Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) IS-O Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t ark � I �t ' b ! rr i 1�d I f s _ • IW/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construcuon permit signed by me dated ��X�f , concerning the property located at M? jg�wg meets all of the following criteria: 4 There are no wetlands located within :oo fee:of:he proposed leaching facility V There are no private wells within 1-40 feet of:he proposed septic syste:n /There is no increase in :how and/or-hanee in-lse::r000sed There are no variances requested or needed. V If the proposed leaching a6iEv wiil �e ;ocatec-vithin =:� 'ee:of any wetlands. the doacm of:he proposed leaching facility will pQ(N :ocated :ess:han fourteen I,1sl 'eet above the rnaxnun adiustec ;roundwater tabu elevation. Please complete the following: _ A P To of Ground Elevation(according:o the Engineering Division G.LS. mapj B)Observed Groundwater Table Elevation(according to Heslth Division well mao) i _._ DATE: SIGNED: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submittedl. a t bUft hMW-00 w 1 g/ O V� 07 LIPS S� I I ��"`�•' S �' � TOWN OF BARNSTABLE LOCATION A Y 9 T 6 i4 SEWAGE VILLAGE ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I O o o G c./!u•,. LEACHING FACILITY: (typee)),. (size) 6 X S NO.OF BEDROOMS- BUILDER OR OWNER PERMIT DATE: 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) S y Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished byT 3 � i 1 TOWN OF BARNSTABLE LOCATION', AAwSEWAGE# �� 3 VU.LAGE ASSESSORS MAP& LOT L 0�ff INSTALLER'S NAME&PHONE NO. t✓On AbIA70t SEPTIC TANK CAPACITY / C.2 LEACHING FACILITY: (type) MILr—, NO.OF BEDROOMS__al__ BUILDER OR OWNER j PERMITDATE: I //8 `—.4 COMPLIANCE DATE: I Z �`� q� 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) Edge of Wetland and Leaching Facili (If any wetlands exist within 300 feet of 1 ng facilit �� Furnished by Feet c 7? - � 10 63t I � 73 - rJAN ATROY WILLIAMS EIVE SEPTIC INSPECTIONS 5 1998 STABLE Certified by MA Department of Environmental Protection HEALTHDEPT. � 385-1300 19 Hummel Drive South Den`u,�,MA b2660 � L 9 �� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION COPY ONE HINTER STREET. BOSTON, MA 02108 617.292.5500 WILLIAM F.WELD TRUDY CORE Govcmor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: /039 a--t l0 y9 RT619� w. �..^<i-m6/e. Address of Owner: Date of Inspection: 1 113 �q 8 (If different) O Name of Inspector: Troy W i 11 i a m s 1 am a DEP approved system inspector pursuant to Section 1S.340 of Title S(310 CMR 1S.000) Company Name: Troy Williams Septic Inspections �arrt.ro� 0jV-4, M`'t Mailing Address: _19 HUmmPI DrivP - tnuth Dennis , MA 026607S- Telephone Number: _(508) 3 8 5-13 0 0 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails - Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, f3, C, or D: Al SYSTEM PASSES: N//9 I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: A/// 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. Indicate yes, no, or not determined (Y, N,or ND). Describe basis of determination in all instances. If'not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection;Of the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (r—ised 04/2s/97) a rage 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1039& 1049 Route 6A,West Barnstable,MA Owner: John Doris Date of Inspection:January 13, 1998 B) SYSTEM CONDITIONALLY PASSES (continued) AV //i Sewage backup or breakout or'high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1039& 1049 Route 6A, West Barnstable,MA Owner: John Doris of Inspection: January 13, 1998 D) SYSTEM FAILS: You m st indicate e,;-.er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No J0 y 9 , /6 3 '} _ Backup of sewage into.4G44y or system component due to an 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. IJrr w�.// �or /d7. oh iy ) N1'9 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. NIA liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. N�/a Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ,u/A Any portion of a cesspool or privy is within a Zone I of a public well. /V//a Any portion of a cesspool or privy is within 50 feet of a private water supply well. k2? 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: N/1 You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (zw1sed 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 1039& 1049 Route 6A,West Barnstable,MA Property Address: John Doris Owner. , Date of Inspection: January 13, 1998 Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or /1139 16419 as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. J _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,.excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _The size and location of the Soil Absorption System on the site has been determined based on: The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1039& 1049 Route GA,West Barnstable,MA Owner: John Doris Date of Inspection: January 13, 1998 /RESIDENTIAL: FLOW CONDITIONS `S�/S fc�..., �-o.� /O,3�/ ) Design flow:2.2 o g.p.d./bedroom for S.A.S. Number of bedrooms: Q Number of current residents: 3 Garbage grinder (yes or no): /V6 Laundry connected to system (yes or no): No (ory w (I ) Seasonal use (yes or no):�/o Water meter readings, if available (last two (2) year'usage (gpd): Pr�tr� 4 l Sump Pump (yes or no): Vo o,, �f p -� Last date of occupancy: COMMERCIAUINDUSTRIAL• ( S y S l�;, '4 Type of establishment: 0o Design flow:267.fS gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present: (yes or no) NO Non-sanitary waste discharged to the Title 5 system: (yes or no) 4/0 Water meter readings, if available: , Last date of occupancy: D OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: / / / / 20.M'- -N 0 Lj�._-- �.a w i �.'7"'Y T`✓D L.o� - o t j,L✓" a d ✓, i A System pumped as pan of inspection: (yes or no) /Vo If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM V _ Septic tank/distribution box/soil absorption system (//a t3p, - )o y 9 S y Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 10-39 -5 57'r, ;., /(L�Q 6 �/ 9 S y .s �u.,, a9 4- ; S �^ !1..o 6 5 Sewage odors detected when arriving at the site: (yes or no)_,�V b (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1039& 1049 Route 6A,West Barnstable,MA Owner: John Doris Date of Inspection: January 13, 1998 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: �S y S�"'^ ]ter �v 3�l '0 -X �a�y G S .) (locate on site plan) Depth below grade: Material of construction: Zoncrete _metal . Fiberglass _Polyethylene —other(explain) If tank is metal, list age — Is age confirmed by Certificate of Compliance —(Yes/No) Dimensions:_ �,� (r �x �,S d d Sludge depth: Q" Distance from top of sludge to bottom of outlet tee or baffle: o? Scum thickness: Nok E Distance from top of scum to top of outlet tee or baffle: /V6 ,S K- Distance from bottom of scum to bottom of outlet tee or baffle:_Ny s C-v HN How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) /w L Tt Z; _ki e- 4\ 2!f a .o✓o, H ti GREASE TRAP:—�V—/4 (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 or 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1039& 1049 Route 6A,West Barnstable,MA Owner: John Doris Date of Inspection: January 13, 1998 TIGHT OR HOLDING TANK:A/41 (Tank must be pumped prior to, or 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 level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_✓ (locate on site plan) Depth of liquid level above outlet invert: to Comments: (note if level and/distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) /� —13d.x � l C.1 u.r r O✓t-r O'-- C 7�'>'�/ /v- / nk PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) Alamo in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/2S/97) Page 7 of 10 i f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 1039& 1049 Route 6A,West Barnstable,MA Date of Inspection:John Doris January 13, 1998 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number.-L,-s; leaching galleries, number: leaching trenches, number,length: 6 _ � leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil,, signs offfl1 hydraulic failure, level of ponding, condition of vegetation, etc..)) ✓ .�. J/O 4- /— i ti O c L /7 Z� CESSPOOLS: �� w��/ ,r �w✓,��r ll (locate on site plan) J Number and configuration: Depth-top of liquid to inlet invert:_ -L,o_�. Depth of solids layer: Depth of scum layer: — Dimensions of cesspool: -y 'I 3 ' Materials of construction: Indication of groundwater: aw., inflow(cesspool must be pumped as part of inspection) Comments: (no condition of soil, signs of h raulic failure, level of ponding, condition of ve e_tation, etc.) 1 1..J / L �' /4 " ti �— ✓ / t J r�.. Gam, / 4 c— 4— d h w r 9 ., t o 1 w v G c Lrv✓ . 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.) (reviead 01/2S/97) Page ! of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 1039& 1049 Route 6A, West Barnstable,MA Date of Inspection: John Doris January 13, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks `(I locate all wells within 100' (Locate where public water supply comes into house) 1039 iZTG � Cl- a 5 o b y�It." SS�8 -73 ,9 5 0 4-- (revised 04/25/97) page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1039& 1049 Route 6A,West Barnstable,MA Owner: Date of Inspection: John Doris January 13, 1998 BUILDING SEWER: A//..q (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC_other (explain) .Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: C S yS 74 /4 y H c y�yL 3 �4 / GS . ) (locate on site plan) Depth below grader Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance —(Yes/No) Dimensions: S !r q 6 Sludge depth: 'L Distance from top of sludge to bottom of outlet tee or baffle: 07 7 '' Scum thickness: Q Distance from top of scum to top of outlet tee or baffle: /. u' / Distance from bottom of scum to bottom of outlet tee or baffle:'' How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) !� u 74 r 0 GREASE TRAP:�/g (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (-i-d 04/25/97) o I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 1039& 1049 Route 6A, West Barnstable,MA Date of Inspection:John Doris January 13, 1998 SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: yr` S �X S `4 -- leaching chambers, number:_ leaching galleries, number: leaching trenches, number,'length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, sign of hydraulic failure, level of ponding, condition of egetation, etc.) UJ La t .J"�✓Q - �— c �.�r �j sr, t O �. W 4Jw f - - LJt 7 J �r Lle, of [ I-CA fa— w a c o r s, f I` v,711111 h i CESSPOOLS: Al/19 (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: A11- (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (reviud 04/2S/97( " Page I of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner 1039& 1049 Route 6A,West Barnstable,MA Date of Inspection: John Doris January 13, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: 10 7 I Sr .S+e„. include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 13 ' 15� �606 yell,., 13 / CM �u.w IL 9 ' 4— (re i<..d 04/25/97) � v.a. • „r in SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1039& 1049 Route 6A,West Barnstable,MA Owner: John Doris Date of Inspection: January 13, 1998 Depth to Groundwater — Feet 7 adjusted high groundwater level Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions V/Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) 8C Aj. �t Qa- clty �� // ' G"A "ta lJ [ L/ .A I- 4-e— Z, 2- O C (revised 04/25/97) Pager 10 of 10 SOWN.•Or= WZ►�Sr�.�l.f :155E5SOR5 MAP. I18 LOTSO <.. . 491Mm s I5 REAR I5� `� ;:�. ��.. ;•'_ s` nT �D1�Fi OP PL'Y'.t=ir_ `+ J `�",-. ! ': '#lly •�C. �r;� A. f � r nsw: Arco •r< :,.'• �.'.`.°!e3s:•\.`=' - {. ,- 66� 1 -gib -� t �� �-• :y � ��, �. 7\�k 7 10 L_ PAZ al =sue, q v1 . 1• • _No: LoWs..:.LvT..L- tE ��.. ���a' vroues wc,.eovuo . ca P EPA o fPR DATE: yy1: � •. � Jy.d r ,ry. •.'fie..v, f ,.. � ��"'(:5N'�. V�' r .. h �{ .,. J .n�o� ► eo�nlN. Z' Pe.o.�i orJe, io11Ho. 10 HUJ. tx�yY ►)t#h� 96PTIC TANK ,p8O6 LEACHING FACILITY I•` 3^I LET i — s.cs a ,1 3.Is' q —+I 3� 5' SECTION- SEWAGE L �411T "TO" o f Yet IJAgrl�.p �S'(D�l� TEST HOLE L065 DESIGN FOR 3gGq tiP TrsreY: I DOGror'� oF*FIGF_ PERC.RAIE• HIN./IN. !N/TNESS:Q 8G C FLOFI RArE 75 GAL.IDAY(fV MO 41F M.8 61P 5EPTIC TANK 289.E (1.5) 4 , 1 P�`COr7Q 8 -REp'O.9EPr1C TANK IOOd �� 3yrg LEACHING FACILITY LOAH — 510E14ALL 2 12tj,(<(Z.iJ•9I4,OG�c tu"6j �i3J8' _ 60rroM )` 7f.�i �1.0), 77.661r L� TOTAL 204.1 5F -1,9 t,y&A USE f'LEACHING I I coacg� — ��•uv NOTES _ 1.DATUM(I{5L)tTAKEN FROM 4'rj,4kjj'i QUADRANGLE MAP 2.HUVICIPAL PATER IS Of AVAILABLE G Y 3.DES14AI LOAOIN6 POR AI.0 PRECA5T U1J1r5:AA590-r f%44 4•PIPE✓0114T5 gNAI.L.BEHAOE HATER rJ6141, .5.CONSTRocr1O1J DEWLSTO Be INACCORDANC6 {JIrH COOK OFMAS5,STATE ENVIRON14C14tAL COOS Tine Y t10 6•THIS PLAN POR PROP05E0114RKONLY AND 6H0U10 Nor yr� RICHARO 1 6E POLO FORPROP@RTY%C►1 SIAKING. R.FAIRBANK T, UTI[IZE EX/Sr'1p11y��/(. No 2020a y 8• F�/s7'!N6 SEPTIL SYS�k'M Tb ,6F'CLE *C N AND INSPEG7�"D TIED (N1v Ol* . DOX y$0, crsTC �o- �1/TN Z OUT T9 A? . (PEOVIDnV6 c pp �a0E \ /J o/awn cope enq/neer1bq CIVI.L ENGINEERS -LAND SURVEYOtLS II 9zro Main 5t.Yar ynouth,mo r -5Z4 board of health APPaHA oVED T3ATE. l3b.F?►J�'�-�I y * :.tY•4S (i•••A � - . � III F ' �A`:r. a .ti - �. �'�.-.e,ep..r•r �q`'^_.,.S`.,.y ...,i�•�+i'a.fffr�S �j�',? Bottle Number: 681901 Date: 01/09/98 BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT p SUPERIOR COURT HOUSE U BARNSTABLE,MASSACHUSETTS 02630 A S 5 PHONE:362-2511 Client: DORISS , DR. JOHN C. Collector: DR. JOHN C. DORISS LAB 337 Mailing 34 AMY LANE Affiliation: OWNER Address : YARMOUTHPORT, MA 02675 Type of Supply: W Telephone: 362-2584 Well Depth: 80 FT Sample Location: 1039-1049 MAIN ST Date of Collection: 01/08/98 Town: WEST BARNSTABLE Date of Analysis : 01/08/98 Map/Parcel: 178 LOT 30 PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100mL 0 0 pH 6.0 Conductivity (micromhos/cm) 791 500 Iron (ppm) < 0. 1 0.3 Nitrate-Nitrogen (ppm) 0. 8 10.0 Sodium (ppm) 12 20.0 Copper (ppm) 0.4 1.3 BASED ON THE ANALYSES PERFORMED, THE FOLLOWING ADVISORIES ARE GIVEN: * Water sample meets the recommended limits for drinking water of all above tested parameters . Thomas F. Bourne, Laboratory Director �� e ��`'•' S � � TOWN OF BARNSTABLE LOCATION A T 6,4 SEWAGE VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1400 d o le b- . LEACHING FACILITY: (typee)/),�.. y` RIO (size) NO.OF BEDROOMS- BUILDER OR OWNER PERMIIDATE: 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) S y Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 3 ° i3 zo. — nJ I J I - ��u 4- I ® Commonwealth of Massachusetts Executive Office of Energy &Environmental Affairs Department of Environmental Protection Southeast Regional Office•20 Riverside Drive, Lakeville MA 02347.508-946-2700 Charles D.Baker Matthew A.Beaton Governor Secretary Karyn E.Polito Martin Suuberg Lieutenant Governor Commissioner April 7,2016 Mr.John Doriss RE:BARNSTABLE-BWSC 1049 Main Street Release Tracking Number:4-0025935 Barnstable, MA 03560 Commercial Property 1049 Main Street NOTICE OF RESPONSIBILITY URGENT LEGAL MATTER:PROMPT ACTION NECESSARY Dear Mr.Doriss: On December 31, 2015 at 4:05 PM the Department of Environmental Protection ("MassDEP") received verbal notification of a release and/or threat of release of oil and/or hazardous material at the above referenced property which requires one or more response actions. During site assessment activities related to a #2 Fuel oil release, C11-C22 Aromatic Hydrocarbons were detected at a concentration of 166 µg/L in an on-site drinking water well. This represents a condition of Substantial Release Migration. The Massachusetts Oil and Hazardous Material Release Prevention and Response Act, M.G.L. c.21E, and the Massachusetts Contingency Plan (the "MCP"), 310 CMR 40.0000, require the performance of response actions to prevent harm to health, safety, public welfare and the environment which may result from this release and/or threat of release and govern the conduct of such actions. The purpose of this notice is to inform you of your legal responsibilities under State law for assessing and/or remediating the release at this property. For purposes of this Notice of Responsibility, the terms and phrases used herein shall have the meaning ascribed to such terms and phrases by the MCP unless the context clearly indicates otherwise. MassDEP has reason to believe that the release and/or threat of release which has been reported Is or may be a disposal site as defined by the M.C.P. MassDEP also has reason to believe that you(as used in this letter, "you" refers to John Doriss) are a Potentially Responsible Party(a "PRP")with liability under M.G.L.c.21E §5,for response action costs. This liability is"strict", meaning that it is not based on fault,but solely on your status as owner, operator, generator, transporter, disposer or other person specified in M.G.L. c.21E §5. This liability is also "joint and several", meaning that you may be liable for all response action costs incurred at a disposal site regardless of the existence of any other liable parties. This Information Is available in alternate format.call Mlchelle Waters-Ekanem,Diversity Dlrector,at 117-292-5751.TTY#MassRelay service 1-800-439.2170 MassDEP website:www.mass.gov/dep Printed on Recycled Paper Release Tracking Number 4-0025935 Page 2 of 3 MassDEP encourages parties with liabilities under M.G.L. c.21E to take prompt and appropriate actions in response to releases and threats of release of oil and/or hazardous materials. By taking prompt action, you may significantly lower your assessment and cleanup costs and/or avoid liability for costs incurred by MassDEP in taking such actions. You may also avoid the imposition of, the amount of or reduce certain annual compliance assurance fees payable under 310 CMR 4.00. Please refer to M.G.L. c.21E for a complete description of potential liability. For your convenience, a summary of liability under M.G.L.c.21E is attached to this notice. You should be aware that you may have claims against third parties for damages,including claims for contribution or reimbursement for the costs of cleanup. Such claims do not exist indefinitely but are governed by laws which establish the time allowed for bringing litigation. MassDEP encourages you to take any action necessary to protect,any such claims you may have against third parties. At the time of verbal notification to MassDEP,the following response actions were approved as an Immediate Response Action(IRA): • Continued assessment. • Excavation and disposal of up to 10 cubic yards of contaminated soil. • All Remediation Waste must be properly stored/handled and disposed of within 120 days from the date of generation per 310 CMR 40.0030. • Provide temporary water supplies. ACTIONS REQUIRED Additional submittals are necessary with regard to this notification including, but not limited to, the filing of a written IRA Plan, IRA Completion Statement and/or a Permanent or Temporary Solution Statement. The MCP requires that a fee of $1,470.00 be submitted to MassDEP when a Permanent Solution Statement is filed greater than 120 days from the date of initial notification. Specific approval is required from MassDEP for the Implementation of all Immediate Response Actions(IRAs)pursuant to 310 CMR 40.0420. Release .Abatement Measures may not be conducted until a RAM Plan is submitted pursuant to 310 CMR 40,0443. Assessment activities, the construction of a fence and/or the posting of signs are actions that are exempt from this approval requirement. . In addition to verbal notification,310 CMR 40.0333 requires that a completed Release Notification Form (BWSC-103, attached) be submitted to MassDEP within sixty (60) calendar days of December 31, 2015. You must employ or engage a Licensed Site Professional ("LSP") to manage, supervise or actually perform the necessary response actions at this site. You may obtain a list of the names and addresses of these licensed professionals from the Board of Registration of Hazardous Waste Site Cleanup Professionals by calling (617) 556-1091 or visiting http://www.state.ma.us/Isp. MassDEP has Brian Snow of OHI Engineering listed as the LSP of Record. Release Tracking Number 4-0025935 Page 3 of 3 Unless otherwise provided by MassDEP, potentially responsible parties ("PRP's") have one year from the initial date of notification to MassDEP of a release or threat of a release, pursuant to 310 CMR 40.0300, or from the date MassDEP issues a Notice of Responsibility,whichever occurs earlier,to file with MassDEP one of the following submittals: (1)a completed Tier Classification Submittal; (2)a Permanent or Temporary Solution Statement or, if applicable, (3) a Downgradient Property Status. The deadline for either of the first two submittals for this disposal site is December 31,2016. This site shall not be deemed to have had all the necessary and required response actions taken unless and until all substantial hazards presented by the release and/or threat of release have been eliminated and a level of No Significant Risk exists or has been achieved in compliance with M.G.L. c.21E and the MCP. If you have any questions relative to this Notice, please contact Andrew L.Jones at the letterhead address or at (508) 946-2785. All future communications regarding this release must reference the following Release Tracking Number:4-0025935. Sincerely, Dan Crafton,Chief Emergency Response/Release Notification Section Bureau of Waste Site Cleanup C/AU/Ig Enclosures: Release Notification Form; BWSC-103 and Instructions Summary of Liability under M.G.L.c.21E ec: Board of Health Board of Selectmen Fire Department 44 Wood Avenue CIF,-. 1 Mansfield, MA 02048 Tel(508)339—3929 Fax(508)339-3140 &1i,.0 ad��t�cs� October 27, 2016 Mr. Thomas McKean Director of Health Division Town of Barnstable 200 Main Street Barnstable, MA 02601 Re: Notice of Permanent Solution Statement and Immediate Response Action Completion Statement 1046 Main Street'Route 6A West Barnstable, MA 02668 DEP Release Tracking Number: 4-25935 To Whom It May Concern: In accordance with the requirements of the Massachusetts Contingency Plan (MCP) [310 CMR 40.0000], OHI Engineering, Inc. (OHI) is notifying you, on behalf of John Doriss of Great Marsh Health Services,that a Permanent Solution Statement with No Conditions has been achieved at the above-referenced location(the "Site"). A Permanent Solution has peen achieved relative to response actions performed under Release Tracking Number(RTN)4-25935, a release of No. 2 fuel oil from an aboveground storage tank(the "Release") at 1049 Main Street/Route 6A in West Barnstable, Massachusetts (the "Site"). Response Actions have been conduct--d that have resulted in a condition of No Significant Risk. The Permanent Solution contains an Immediate Response Action(IRA) Completion Statement. The original Permanent Solution Statement and report has been submitted to the MassDEP Southeast Regional Office in Lakeville, Massachusetts, and is available for public review at http://public.dep.state.ma.us/SearchableSites2/Search.aspx. Please do not hesitate to contact OHI should you have any questions regarding this matter. Sincerely, OHI Engineering,Inc. Brian G. Snow, P.G., LSP,LEP Senior Project Manager Cc: John Doriss—current owner i C-1i T 44 Wood Avenue Mansfield,MA 02048 Tel(508) 339-3929 (9.#-9 -9ac. Fax(508)339-3140 L'r�.ev�.����t�'ciesstrdts March 4, 2016 t�► v r Town of Barnstable Health Division 200 Main Street Hyannis MA 02601 Attn: Thomas Mckean., Director Re: .Notice of Immediate Response Action Plan 1049 Main Street/Route 6A West Barnstable, Massachusetts DEP Release Tracking Number: 4-25935 Dear Mr. Mckean: In accordance with the requirements of the Massachusetts Contingency Plan(MCP) [310 CMR 40.0000] and Department of Environmental Protection(DEP), OHI Engineering, Inc. (OHI) is notifying you, on behalf of John Doriss,that an Immediate Response Action Plan has been prepared for the above- referenced location, and has been submitted to the Massachusetts Department of Environmental Protection(MADEP) Southeast Regional Office in Lakeville,Massachusetts. Copies of the report may be obtained from the M_ADEP website at http://public.dep.state.ma.us/SearchableSites2/Search.aspx or by contacting the undersigned. The Immediate Response Action Plan documents the activities undertaken to remediate a release of#2 fuel oil from an aboveground storage tank in the basement of 1049 Main Street in West Barnstable,MA. IRA activities include the excavation of contaminated soil beneath the basement. Assessment and response activities will be conducted as documented in the referenced IRA Plan. Please do not hesitate to contact OHI should you have any questions regarding this matter. Sincerely, OHI Engineering,Inc. Brian G. Snow,P.G.,LSP,LEP Project Manager Cc: John Doriss - r TOWN OF BARNSTABLE t'. I LOCATION::'` m % 1��� r � l//9 SEW AGE # MLA /1 ASSESSOR'S MAP & LOT INSTALI:MS`;NAME&PHONE NO. Bdtf APo llJ e6Y57: 77/-!e, � i SEPTIC TANK CAPACITY �oopG,�L LEACHING>FACILI TY: (type) roo 64 CAN tal (size) 49.f S AT� NO.OF BtDRI�OMS BUILDER'0 �i�� /�a rS C�i��7rpsaaf�G / 4 PERMTTD.A`I ; COMPLIANCE DATE: if - SeparatiotDistahce Between the: , :.I Maximum:Adjusted Groundwater Table and Bottom of Leaching Facility Facili �f Feet - Private Water:Supply Well and Leaching Facility (If any wells exist on site':ot'::within 200 feet of leaching facility) 4IS404 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within-3.00:feet of leaching facility) Feet Furnished'b""' ' I O .Ao/ir- . r� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENERGY& ENVIRONMNTAT, AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTE Ce py SOUTHEAST REGIONAL OFFICE U 20 RIVERSIDE DRIVE,LAKEVILLE,MA 02347 508-9 6-2700 DEVAL L.PATRICK IAN A.BOWLES Governor Secretary TIMOTHY P.MURRAY LAURIE BURT Lieutenant Governor Commissioner December 31,2009 Great Marsh Chiropractic RE: Barnstable P.O.Box 122 Great Marsh Health Services West Barnstable,Massachusetts 02668 PWS ID#: 4020022 Sanitary Survey Dear Public Water System Official: Please find attached the following information: Sanitary Survey Report for a survey performed at Great Marsh Health Services,West Barnstable, MA on December 16,2009. Please note,the signature on this cover letter indicates formal issuance of the attached document. If you have any questions regarding this letter,please contact Terry Dayian at 508-946-2765. Ve ruly yQ rs, Richard J.Rondeau,Chief Drinking Water Program _ Bureau of Resource Protection o R/TM/cb CD: o cc: Barnstable Health Department Enclosure: Attachment A—Emergency Contact List ra W w r V rr1 Y:\DWP Archive\SERO\Barnstable-4020022-Sanitary Survey-2009-12-31 TM\greatmarshss09 This information is available in alternate format.Call Donald M.Gomes,ADA Coordinator at 617-556-1057.TDDH 866-539-7622 or 617-574-6868. DEP on the World Wide Web: http://www.mass.gov/dep Z"w1 Printed on Recycled Paper Great Marsh Health Services Bamstable 4020022 Survey Date: December 16,2009 Public Water System Sanitary Survey CITY: Barnstable PWSID: 4020022 PWS NAME: Great Marsh Health Services Survey Date: December 16, 2009 — Report Date: December 31, 2009 Surveyor: Terry Martin Affiliation: DEP Person Interviewed: Dr. John Doriss Title: Certified Operator Person Interviewed: Person Interviewed: PUBLIC WATER SUPPLIERS: Attached is a Sanitary Survey Report for the above referenced sanitary survey site visit. At the end of the report is a Water System Compliance Plan which consists of the. following (checked items only): ❑ Table A - Summary of violations and Notice of Noncompliance (if violations were observed during the survey) Table B—Summary of deficiencies and required corrective actions ❑ Table C—Recommendations ❑ Water supplier response and certification. Within 60 days of receipt of this inspection report, you must complete and submit the. response form if your system has TABLE A—Violations and/or TABLE B-Deficiencies. Attach a copy of each completed table listing the date that the corrective action was or will.be taken by your system and all other applicable documentation. (310 CMR 22.04(12)) i 2 Great Marsh Health Services Barnstable 4020022 Survey Date: December 16,2009 SYSTEM DESCRIPTION: System consists of a single, 2-inch diameter driven well installed to a depth of approximately 70-80 feet, which is pumped via a Goulds 1 horsepower centrifugal (jet) pump, located in a basement area of the building. The jet pump then feeds to two hydropneumatic "Well Mate" storage tanks for pressure control. There is no treatment, and the system is metered. ADMINISTRATION: General System Information Is this correct? Yes No ❑ PWSID PWS Class Season Start Season End Population Served(Summer) Population(Winter) 4020022 TNC 101 1231 25 25 Facility Address: Is this correct? Yes [✓l No ❑ Name Address Town Zip Entail Phone# Fax# GREAT 1049 ROUTE WEST 02688 GREATMARSH@VERIZON.NET 508-362- 508-362- MARSH 6A BARNSTABLE 4533 5151 HEALTH SERVICES Mailing Address: ❑ Is this correct. Yes No Name Mailing Address Town State 'Zip GREAT MARSH HEALTH P.O.BOX 122 WEST MA 02688 SERVICES BARNSTABLE _ _- Contact Information Is this correct? Yes No PWSID# First MI Last Address Address Town State Zip Work Primary (2) Phone# Contact? 4020022 J014N DORISS P.O. WEST MA 02688 508- y BOX BARNSTABLE 362- 122 4533 Comments:, Certified Operator Information: Is this correct? Yes No ❑ PWSID# First MI Last Address Town State Zip Work Phone# 4020022 JOHN DORISS P.O.BOX 122 WEST MA 02688 508-362- BARNSTABLE 4533 PWSID# PWS:Vlaximum Treatment Class Distribution Class 4020022 NO TREATMENT VSS 3 • Great Marsh Health Services Barnstable 4020022 Survey Date: December 16,2009 PWSIDtt Distribution Class Population Served 4020022 vss 25 Are operator grades appropriate for system size and/or treatment type? Yes No ❑ Does the system have the correct staffing levels for the system size and grade? Yes No ❑ Is certified operator or a backup operator available for emergencies? Yes 0 No ❑ Comments: Derek Ricthie, a licensed T3, D1 operator, provides back up certification for this system and is responsible for certain aspects of system compliance. OPERATION AND MAINTENANCE: Is there an adequate spare parts inventory? Yes Z No ❑ Is there an O & M Manual?N/A—TNC w/no treatment Yes El No Z Is there a preventative maintenance program? Yes No ❑ Are operational records collected appropriately? Yes No ❑ Are records properly maintained and available for review? Yes No1.11 ❑ Frequency of meter readings? Daily ❑ Monthly Z Other ❑ How frequently are meters calibrated? Installed in 2006/2007 • The Department recommends that source meters be calibrated on an annual basis. Are emergency telephone numbers posted? Yes ❑ No Is there a plan/procedure for emergency repairs and spare parts? Contracted as needed Yes No ❑ Who performs emergency repairs? Contracted as needed Comments: TREATMENT - GENERAL: Active treatment plant information listed within Department records: 4 Great Marsh Health Services Barnstable 4020022 Survey Date: December 16,2009 Treatment listed Unapproved treatment No Treatment `� above is correct `� installed ❑ • Unapproved treatment is subject to MassDEP permit requirements If a sediment filter is being utilized how often is the filter replaced? N/A No Is information from the manufacturer available for reference? Yes ❑ ❑ N/A 0 Is chemical storage, containment, and safety equipment adequate? Yes ❑ No ❑ N/A No Is equipment properly maintained? Yes ❑ ❑ N/A R1 Are alarms tested and adequate? Yes ❑ No ❑ N/A Are chemical treatment forms submitted monthly as required? Yes ❑ No ❑ N/A No Are they completed properly? Yes ❑ ❑ N/A 0 No Is operator familiar with the treatment system and its operation? Yes ❑ ❑ N/A STORAGE: Maintenance and Condition PWSID# Storage Storage Type Tank Material Capacity Last Last Structural Tank (G) Inspection Cleaned Integrity- Name Date Date Condition 4020022 TANK#1 HYDROPNEUMATIC STEEL/FIBERGLASS 3040 N/A N/A GOOD and#2 EACH • MassDEP recommends storage tanks be inspected and cleaned every 5 years. Protection and Safety STORAGE Proper Covered/ Vented/ Sample lligh/Low By-pass for Protected from Protected Fenced or TANK Overflow? Locked? Screened? Tap? Level Repair/ Flooding from otherwise alarms? Cleaning (>50ft)? Runoff? protected? ##2 NK#1 AND N/A Y N/A Y N Y Y Y Y The storage tanks have nearby injection ports to allow emergency disinfection. Yes 2 No ❑ 5 Great Marsh Health Services Bamstable 4020022 Survey Date: December 16,2009 No The storage tanks are adequately protected against vandalism. Yes ❑ Comments: The storage tanks/system could be chlorinated via modification of a pressure gauge fitting located after the jet pump. PUMPING STATIONS: PWSID Pump Stn Hof Pumps Avail Water GPM Emerg Motor HP Motor Type Name Type Power? 4020022 WELL 41 1 ACTIVE R 2 N 1 CENTRIFUGAL PUMP Are all pump stations recorded in WQTS? Yes 21 No ❑ Are pump stations adequately maintained? Yes No ❑ Comments: DISTRIBUTION Has the system submitted a distribution map to MassDEP Yes ❑ No R1 Are valve locations known or identified? Yes ❑ No How many distribution systems are there? 1 Is adequate pressure being maintained? (20-60 psi) Yes 2 No ❑ List distribution system weaknesses or problems No known weaknesses or problems Date of last leak detection survey: N/A TNC Percent of system surveyed? N/A Are distribution valves exercised regularly? Yes ❑ Frequency? No Is there a hydrant maintenance program? TNC SYSTEM Yes ❑ No Is there an adequate flushing program? TNC SYSTEM Yes ❑ No • The Department recommends that the distribution system be flushed twice.a year. Comments: 6 Great Marsh Health Services Bamstable 4020022 Survey Date: December 16,2009 CROSS-CONNECTIONS / BACKFLOW PREVENTION: PWSID# Does System Have Approved Cross Connection Plan? Was X-Conn Survey Conducted? 4020022 Y Y Does the system annually report its cross connection activities of the previous year within its `Annual Statistical Report'? Yes ❑ No If the system has any testable devices (RPBP or DCVA)—Does the system keep an inventory list of the devices, including type of device, location and device test inspection dates? Yes ❑ No Has the system undergone any modifications since the last cross connection survey? Yes ❑ No Date of Last Survey: 2006 Comments: See Table B below for corrective actions related to the cross connection program. SAMPLING: PWSID# No of Bacteria Samples(Summer) Frequency(Summer) No of Bacteria Samples(Winter) Frequency(Winter) 4020022 1 QUARTER I QUARTER Does the system have an approved Total Coliform Sampling Plan? Yes No ❑ Is the system taking the correct number of bacteria samples? Yes No ❑ Is the system using appropriate coliform sample sites? Yes Q No ❑ Is the system using appropriate source sample sites? Yes No ❑ Are raw water sample taps available for all sources? Yes ❑ No Comments: Can collect raw water sample from storage tank drain. SOURCES: Are all wells recorded in `VQTS? Yes No ❑ Are all of the wells listed on the sampling schedule? Yes Q No ❑ Are manifolded wells reflected accurately on the schedule? Yes ❑ No ❑ N/A Is the quantity of water supply adequate? Yes No ❑ Do any sources run dry? Yes ❑ No 7 I Great Marsh Health Services Barnstable 4020022 Survey Date: December 16,2009 If yes, during which periods and how is it handled? Comments: Source Protection: SWAP Database Information Source ID Approved Zone I Zone 1 Zoned(ft) Pollution Volume(MGD) Owned? Method Sources in Zone I 4020022-OIG 1,000 NO Default 100 roadways, parkign areas Is there excessive use of fertilizers or chemicals in Zone I? Yes ❑ No Are there any open floor drains in the facility? Yes ❑ No Are there any known or potential, sources of pollution observed in the Zone I or IWPA (other than those listed above)? Yes ❑ No Is there an awareness of threats and an attempt to minimize them? Yes No ❑ Is protection area posted?Front lawn of facility Yes ❑ No Are source water protection measures adequate? Yes .2 No ❑ Comments: OTHER ISSUES OBSERVED: No other issues were observed during this inspection. There are no outstanding enforcement actions for this system. 8 r Great Marsh Health Services Bamstable 4020022 Survey Date: December 16,2009 Table B - Deficiencies MassDEP has made note of several items that do not reflect good water system practice and, if left unresolved,could lead to problems that are more serious. Some of these items may be potential violations,and are summarized below.Due to the item's severity or importance MassDEP has included a required course of action with a compliance date. C Date,: T/F/M Cttation Actton Due 7 TABLE B CORRECTIVE ACTION Complete Date b 'PWS 1. T 310 CMR The system must keep an updated list of approved-cross-connection 3/1/1009 22.22 devices, including copies of test results for each device.Each approved device must be tested in accordance with 310 CMR 22.22(13)(d). Please provide MassDEP with a schedule to conduct the necessary backflow testing by a licensed tester.A list of licensed testers is available from the MassDEP website at: www.mass.gov/dep/water/cclist.xls 2. T Guidelines, Please complete and post the enclosed Emergency.Contact List, 1/30/09 Appendix Attachment A from the Handbook of Water Supply Emergencies,at the O - facility in an accessible location. Table C -Recommendations MassDEP has made note of items with a recommended course of action,summarized in Table C.It is strongly encouraged to follow the recommended actions in order to improve ability to provide a safe supply of drinking water.Failure to do so could . eventually lead to violations of the regulations. f T/F/M Citation TABLE C-RECOMMENDATIONS 1. T/F/M-Technical/Financial/Managerial 9 Great Marsh Health Services Bamstable 4020022 Survey Date: December 16,2009 SANITARY SURVEY COMPLIANCE PLAN RESPONSE FORM for TABLE A & B Within 60 days of receipt of this inspection report,you must complete and submit this response form if your system has TABLE A—Violations and/or TABLE B-Deficiencies.Attach a copy of the completed tables listing the date that the corrective action was or will be taken by your system and all other applicable documentation. (310 CMR 22.04(12)) Please note that violations listed in TABLE A of the Compliance Plan are also a Notice of Noncompliance (NON) pursuant to M.G.L. c.21A, §16 and 310 C.M.R. 5.00 and may require the submission of quarterly written progress reports on the identified violations. The following corrective actions listed in the Sanitary Survey Compliance Plan(s)TABLE A and/or B has been taken by the public water system.(Please check all that apply). My system has taken ALL of the corrective actions listed within the timeframes specified in the Sanitary Survey Compliance Plan(s). • For each item, I have listed the completion date of the corrective action within each table. • I have attached copies of supporting documentation as required. ❑ My system has taken SOME BUT NOT ALL of the corrective actions listed within the timeframes specified in the Sanitary Survey Compliance Plan(s). My system HAS NOT complied with ALL of the . requirements set forth in the Sanitary Survey Compliance Plan(s). • For each item, I have listed the actual or anticipated completion date of the corrective action within each table. • 1 have attached copies of supporting documentation as required. e I_have attached a revised.corrective action schedule establishing timelines for my system to address outstanding items and I will submit a written progress report each quarter(every 3 months) until all items have been addressed. I understand that my system may be subject to further enforcement action. ❑ My system is UNABLE to comply with some or all of the corrective actions within the timeframes specified in the Sanitary Survey Compliance Plan(s). I understand that my system may be subject to further enforcement action. • An explanation is attached. I hereby acknowledge receipt of the inspection findings and compliance plan table(s)of the sanitary survey conducted by the Department of Environmental Protection's Drinking Water Program. I certify that under penalty of law I am the person authorized to fill out this form and the information contained herein is true, accurate and complete to the best of my knowledge and belief. Water Commissioner,Owner,Owner Representative or Other Responsible Party: Signature: Date: Print Name: Title: Return this form, a copy of each Compliance Plan Table and all attachments to: DEP-BRP Drinking Water Program,20 Riverside Drive,Lakeville,MA 02347,ATTN: Terry Dayian 10 'Massachusetts Department of Environmental Protection Bureau of Resource Protection -Drinking Water Program TRANSIENT NON-COMMUNITY (TNC) VIOLATION NOTICE OF NONCOMPLIANCE (NON) Enforcement Notice: M.G.L.c.21A sec. 16,310 CMR 5.00 gV•, Attention: Owner/Owner representative/Responsible party: NON - BO-.16 - 5DO01 Genera/Information r+- PWS NAME: GREAT MARSH HEALTH SERVICES DATE: 7/5/2016 �~+ P.O.BOX 122 1049 MAIN STREET PWSID: 4020022 i•+ CLASS: NC WEST BARNSTABLE MA 02668 CITYITOWN: WEST BARNSTABLE Location Where Noncompliance Occurred: GREAT MARSH HEALTH SERVICES Description of Violations under M.G.L. c. 111 sec. 159-160 and 310 CMR 22.00 and Corrective Actions to Take and Deadlines for Taking Such Actions: 1. The Department of Environmental Protection(MassDEP), Drinking Water Program(DWP), records indicate that your system is in violation of the following checked(X)requirements as of the date in Section A above. In order to return to compliance your system must take the corrective action(s)by the prescribed deadline(s): Within 30 days of receiving this NON You must complete,sign and submit an electronic Annual Statistical Report via eDEP. Detailed instructions are available at http://wWw.mass.gov/eea/agencies/massdep/water/approvals/drinking-water-forms.htm1#16. Failure to submit the 2015 You must also complete and submit the attached TNC Violation Response Form to MassDEP/DWP, 1 Winter X Annual Statistical Report to Street,5th Floor, Boston,MA 02108,Attention: Andrew Durham. the Department by March 16,2016,as required by Or 310 CMR 22.15; You must sign and submit the attached Hardship Application Form along with a completed Violation Response Form to MassDEP/DWP, 1 Winter Street,5th Floor, Boston,MA 02108,Attention: Tio Yano. MassDEP/DWP will then mail you a paper copy of the Annual Statistical Report which,within 30 days of. receipt,you must complete,sign and submit. Within 30 days of receiving this NON You must contract for the services of a Massachusetts certified operator of the required grade and submit the attached Public Water System Certified Operator Compliance Notice along with a completed Violation Response Form to MassDEP/DWP, 1 Winter Street, 5th Floor, Boston,MA 02108,Attention: Andrew Operating a public water Or system without a certified You must apply to the Board of Certification of Operators of Drinking Water Supply Facilities for a temporary operator as required by 310 six-month emergency certification`and submit a copy of the completed application along with a completed CMR 22.11 E(1); Violation Response Form to MassDEP/DWP, 1 Winter Street,5th Floor, Boston,MA 02108,Attention: Andrew Durham In addition,within 6 months of receiving this NON Your system must be operated by personnel that fulfill the certified operator requirements as stated in 310 CMR 22.11E(1)and(2). 'To apply for a temporary six-month emergency certification you must completely fill out and mail the attached Temporary Emergency Certification Application along with the required fee, to the Board at 1000 Washington Street, Suite 710,Boston, MA 02118-6100. Failure to submit a cross Within 30 days of receiving this NON You must complete and submit the attached Cross Connection connection control program plan Control Program Plan Questionaire for TNC Public Water Systems and submit 2 copies along with a to the Department,as required completed TNC Violation Response Form to MassDEP/DWP, 1 Winter Street,5th Floor, Boston,MA 02108, by 310 CMR 22.22(3); Attention: Andrew Durham 2. If your system HAS COMPLIED with any or all of the requirements listed and checked(X)above,you must submit proof. Examples of proof include copies of return receipt postcards from the post office postmarked prior to the deadline(s).You must submit the proof and 2 copies of the required information along with a completed Violation Response Form to MassDEP/DWP, 1 Winter Street, 5th Floor, Boston, MA 02108,Attention Andrew Durham. _ Important Information 1■i An administrative penalty may be assessed for every day from now on that you are in noncompliance with the requirements described in this NON. Notwithstanding this NON,the Department reserves the right to exercise the full extent of its legal authority in order to obtain full compliance with all applicable requirements including,but not limited to,criminal prosecution,civil action,including court-imposed civil penalties or administrative penalties assessed by the Department. If you have any questions about this NON please call Andrew Durham at 617-574-6855. Attachments cc: MassDEP Boston-Office of Enforcement Yvette DePeiza, Program Director MassDEP Regional Office-DWP Drinking Water Program Local BOH Bureau of Resource Protection/MassDEP 0 Certified Operator Massachusetts Department of Environmental Protection Bureau of Resource Protection -Drinking Water Program - TRANSIENT NON-COMMUNITY VIOLATION RESPONSE FORM(TNCVRF) M.G.L.c.21A sec. 16,310 CMR 5.00 Attention: MassDEP/Drinking Water Program ' General Information DATE: 7/5/2016 d PWS NAME: GREAT MARSH HEALTH SERVICES RE: NON - BO- 16 - 5DO01 -� P.O. BOX 122 1049 MAIN STREET PWSID: 4020022 CLASS: NC —; WEST BARNSTABLE MA 02668 CITY/TOWN: WEST BARNSTABLE Location Where Noncompliance Occurred: GREAT MARSH HEALTH SERVICES Description of Corrective Action Taken under M.G.L. c. 111 sec. 159-160 and 310 CMR 22.00: My public water system has taken the following actions to correct the violations listed in the above referenced NON. (please check all that apply) ❑ My system DID submit the 2015 Annual Statistical report to MassDEP by the required deadline Within 30 days of receiving the above referenced NON I am submitting this form and a copy of the eDEP receipt that proves that my system submitted this report by the deadline. Failure to submit the 2015 Annual Statistical report to the ❑ My system DID NOT submit the 2015 Annual Statistical report. Within 30 days of receiving the above Department by March 16,2016,as U referenced NON 'I am submitting this form and(select one): required by 310 CMR 22.15; ❑ 1 will complete,sign and submit an electronic Annual Statistical Report via eDEP ❑ a signed Hardship Application Forma Within 30 days of receiving the paper copy of the Annual Statistical Report I will complete,sign and submit it. ❑ My system HAS the required Certified Operator and DID report to the MassDEP this change in operator status as required. Within 30 days of receiving the above referenced NON I am submitting proof that my system has the required Certified Operator and had properly notified the Department.See attached photocopies of the license(s),contracts)and other supporting documentation that proves my system submitted this information by the deadline. I have completed the Certified Operator Status Table below. ❑ My system HAS the required Certified Operator but DID NOT report to the MassDEP any changes in operator status as required. Within 30 days of receiving the above referenced NON I am submitting proof that my Operating a public water system system has the required Certified Operator. See attached photocopies of the license(s)and,contract(s). I have without a certified operator as completed the Certified Operator Status Table below. required by 310 CMR 22.11 B(1); ❑ My system DID NOT have the required Certified Operator. Within 30 days of receiving the above referenced NON my system has(select one): ❑ Obtained the services of a Certified Operator of the required certification grade and completed and submitted a Public Water System Certified Operator Compliance Notice form to the Board for verification and signature.See attached copy of the completed form. I have completed the Certified Operator Status Table below. ❑ Applied to the Board for a temporary six-month emergency certification(copy attached). I understand that within six months of receipt of the above referenced NON my system must be operated by personnel that fulfill the certified operator requirement as stated in 310 CMR 22.11E(1)and(2). ❑ I will report all future changes in my system's Certified Operator status to DEP within.24 hours of such changes. I will also provide MassDEP with written documentation of the change within 30 days. ❑ My system DID submit a Cross Connection Control Program(CCCP)Plan to DEP by the required deadline. Failure to submit a cross- Within 30 days of receivinq the above referenced NON I am submiting this form,two(2)copies of connection control program plan to the completed CCCP Plan Questionaire for TNC Public Water Systems and documentation that proves that the Department,as required by 310 CMR 22.22(3); my system submitted this report by the deadline. ❑ My system DID NOT submit a Cross Connection Control Program(CCCP)Plan. Within 30 days of receiving the above referenced NON I am submitting this form and two(2)copies of the completed CCCP Plan. ❑ My system was unable to meet some or all of the corrective action requirements identified in the above referenced NON.An explanation is attached. I understand that I may be subject to further enforcement action. Name/Address/Phone# Licence# Grade Approximate dates of planned routine monthly site inspection Certified Operator Owner,Owner Representative,Water Commissioner or other Responsible Party: Print Name: Title: Phone#: ( ) Signature: Date: Email address cc:MassDEP/DWP Regional Office,Local Board of Health Please complete and return this response form to: MassDEP/DWP,1 Winter Street,5th Floor,Boston,MA 02108,Attention: Andrew Durham il-FAII 44 Wood Avenue Mansfield,MA 02048 Tel(508) 339—3929 C9#9 eaqi�, .9ac. Fax(508)339 -3140 March 4,2016 r Town of Barnstable 3> s Health Division 200 Main Street Hyannis MA 02601 A . Attn: Thomas Mckean,Director Re: Notice of Immediate Response Action Plan 1049 Main Street/Route 6A est arnstable,Massachusetts DEP Release Tracking Number: 4-25935 Dear Mr.Mckean: In accordance with the requirements of the Massachusetts Contingency Plan(MCP) [310 CMR 40.0000] and Department of Environmental Protection(DEP),OHI Engineering,Inc. (OHI) is notifying you, on behalf of John Doriss,that an Immediate Response Action Plan has been prepared for the above- referenced location, and has been submitted to the Massachusetts Department of Environmental Protection(MADEP) Southeast Regional Office in Lakeville,Massachusetts. Copies of the report may be obtained from the MADEP website at http://public.dep.state.ma.us/SearchableSites2/Search.gWx or by contacting the undersigned. The Immediate Response Action Plan documents the activities undertaken to remediate a_release of#2 fuel oil from an aboveground storage tank in the basement of 1049 Main Street in West Bamsta e MA. URA activities me u e t e excava ion o contaminate soi eneat tFie asement. Assessment and response activities will be conducted as documented in the referenced IRA Plan. Please do not hesitate to contact OHI should you have any questions regarding this matter. Sincerely, OHI Engineering,Inc. Brian G. Snow,P.G.,LSP,LEP Project Manager Cc: Johdboriss r Massachusetts Department of Environmental Protection-- Drinking Water Program N Nitrate Report Please refer to our DEP Water Quah Sam lin Schedule(WQSS to hel com lete this form I. PWS INFORMATION: y ty'.. p. 9.. ) p P PWS ID#: 4020022 City/Town: W Barnstable PWS Name: lGreat Marsh Health Services p LVQ U Q PWS Class: COM ❑ NTNC 0 TNC ❑ DEP.LOCATION Sample Date DEP Location Name Sample Information Collected By (LOC)ID# Acidified? Collected Lj q 10000 Sink in Basement (M)ultiple � (R)aw Yes El 9/15/2015 D. Ritchie 0 (S)ingle ❑ (F)inished B ❑ (M)ultiple ❑ (R)aw Yes ❑ ❑ (S)ingle ❑ (F)inished C ❑ (M)ultiple ❑ (R)aw Yes ❑ ❑ Mingle ❑ Finished D ❑ (M)ultiple El (R)aw Yes ❑ El (S)ingle ❑ (F)inished Routrne;:or. Ongrrial,Resubmittetl or::: If;Resubmrtted Re•ort is-I- Special Sample Corifirmation Report (1,)Reason for Resubmission (2)Original Sample Collected Date A RS ❑ SS W Original ❑ Resubmitted ❑ Confirmation Resample❑ Reanalysis ❑ Report Correction B iJ RS ❑ SS ❑ Original ❑ Resubmitted ❑ Confirmation Resample❑ Reanalysis ❑ Report Correction C ❑ RS ❑ SS ❑ Original ❑ Resubmitted ❑ Confirmation Resample❑ Reanalysis ❑ Report Correction D ❑ RS ❑ SS ❑ Original ❑ Resubmitted ❑.Confirmation. Resample❑ Reanalysis ❑ Report Correction SAMPLE NOTES (Such.;as, if a Manifold/Multiple sample,list the sources that were on-line during sample collection) A B C D II.:ANALYTICAL LABORATORY INFORMATION Primary Lab MA Cert#: M=MA009 Primary Lab Name: Barnstable County Health Lab Subcontracted?(Y/N) Na Analysis Lab MA Cert#: Analysis Lab Name: NITRATE MCL MDL Lab Lab Method Date analyzed Result(mg/L) (mglL) (mglL) Sample ID# A 1.5 10: 0.10 EPA 300.0 9/15/2015 1590330-01 B 10;` C 70 D 10 Finished water results equal to or exceeding 1/2 of the MCL(5 mg/L)triggers quarterly monitoring. Finished water results exceeding the MCL of 10 mg/L,requires confirmation sampling within 24 hours. Notify MassDEP of anV MCL exceedances. LAB SAMPLE NOTES A B C D I certify under penalties oflaw thatl;am.the•person Primary Lab Director Signature: 's authorized to f. out this fo m and the:information contained herein is Date: �® true accurate and complete to.the best extent of,my knowledge If not submitting these results electronically,mail TWO copies of this report to your DEP Regional Office no later than 10 days after the end of the month in which you received this report or no later than 10 days after the end of the reporting period,whichever is sooner. DEP REVIEW STATUS(Initial and Date) Review WOTS 0 Accepted Disapproved. Comments Data Entered Massachusetts Department of Environmental Protection - Drinking Water Program B BACTERIOLOGICAL REPORT I. PWS INFORMATION: Refer to your MassDEP Coliform Sampling Plan to help complete the PWS Information and MassDEP Approved Sample Site Information sections below. PWS ID#: 14020022 PWS Name: Great Marsh Health Services I City/Town: JW. Barnstable Class: COM ❑ NTNC Se TNC II.. ANALYTICAL INFORMATION: Refer to your MassDEP state lab certificate for proper Lab MA Cert#and certified methods. Primary Lab MA Cert.#: I M-MA009 Primary Lab Name: Barnstable County Health Department Lab Subcontracted?(Y/N) Q Analysis Lab MA Cert.#: Analysis Lab Name: Original Report ❑ Resubmitted Report ❑ confirmation Report (1)Reason for Resubmission: Resample Reanalysis Report Correction (2)Collection Date of Original Sample Total Coliform E. Co/i Enterococci Fecal Coliform HPC Lab Sample Notes (TC)Method (EC)Method (ET)Method (FC)Method Ze Method ENZ.SUB.SM9223 MassDEP Approved Sample Site Information Chlorine HPC COLLECTION ANALYSIS TC4,5 EC 4.5 ET 4.5 FC 2B,4 Result'° Result COLLECTED LAB SAMPLE Sample Location � Type'' code#1 Approved SAMPLE LOCATION Result Result Result Result mg/L #cfu/mL DATE TIME DATE TIME BY ID# RS 10000 Sink in Basement A 9/15/2015 11:20 9/15/2015 15:30 D.Ritchie 1590330-01 Sample Type,Location Code#,.and Approved Sample Location must correspond to the sample information on your MassDEP Coliform Sampling Plan. 2A SWTR systems:HPC samples shall be taken at the same distribution sites,and at the same time as total coliform,whenever chlorine residual is not detected at the sample site. ZBFecal reporting is for unfiltered SWTR sources only 3 Sample Type:RS-Routine Distribution Sample,RO-Original Site Repeat,UR-Upstream Repeat,DR-Downstream Repeat,AR-Additional Repeat,RW-Raw Water,PT-Plant-rap,SS-Special Sample. 4 Report as#/100 ml-,P(present),A(Absent),or Too Numerous To Count:TNTC-1(invalid)or TNTC-P(present). Notify MassDEP of any E coli or enterococci positive results by the end of the business day. 5 Collect appropriate,number of repeat samples within 24 hours of laboratory notification for total coliform-positive or invalid samples and E.coli or enterococci positive raw water samples. I certify under penalties of law that I am the person authorized to fill out this form and the information Laboratory authorized contained herein Is true,accurate and complete to the best extent of my knowledge. signature and date: DER Review Status: Accepted Disapproved Review Comments: Massachusetts Department of Environmental Protection - Drinking Water Program B "A BACTERIOLOGICAL REPORT "-0LE ME _&VIVII e' INE 'AP 9 in,a, 1290MB MA tj4DEj cs pi jffl 51 i PWS 16#: 14020022 PWS Name: lGreat Marsh Health Services City/T6wh jl� est Barnstable M ❑ NTNCEI TNC W j Class: Co M Bb_ N V certificate AMp't'j,# 'Ll Subco Barnstable Primary Lab MA Cert.#: Primary Lab Name: le Co nty Health Department Lab ntracte ?.,.(Y/N) Analysis Lab MA Cert#: Analysis Lab: F�_Original Report Hl',eport Correction (2)Collection Date of Ori,g1naLSample' Resubmitted Report E] Confirmation Report (1)Reason for Resubmission_:JE]�Resampl�i7E:]_'Reanyysij!�j 'Report J TC Method E. Coli Method Fecal Coliform HPC Method Lab Sample Notes: MF-SM9222B ICOLLECTION DEP APPROVED SAMPLE SITE INFORMATION -L COLT ,A RA A9 C— VyVAl r q !e 'p?p". � � J0imqii uini. - M � p- x RS 10000 Sink in Basement 0 3/10/2008 10:30 3/10/2008 12:47 I.DerekRitchie 845336-01 1 DEP Sample Type,Location Code and DEP Approved Sample Site Location must correspond to the sample information on your DEP Total Coliform Sampling Plan. 2 SVVT R systems:H PC samples shall be taken at the same distribution sites,and at the same time as total coliform,whenever chlorine resival is not detected at the sample site. 3 Sample Type:RS-Routi ne Distribution Sample,RO-Original Site Repeat,UR-Upstream Repeat,DR-Downstream Repeat,AR.AdditionalRepeat,RW-RawWater,PT-Plant Tap,SS-Special Sample. 4 Report as#/100 mL,P(present),A(Absent),or Too Numerous To Count TNTC-1(invalid)or TNTC-P(present). $ Collect appropriate number of repeat samples within 24 hours of laboratory notification for coliform-positive or invalid samples. Notify DEP of any routine or repeat E.Coli or fecal positive results by theend of the business day. certify" under penalties of law that I amcthe person authorized to fill out thrs form andthe J YV ;arm Laboratory authorized contained herern,rs,true accurate aril complete -s i ftf t4e,be t at.4k*njo*hedge.U!e"" zza A,_x signature and date: ..... DEP Review Status: 10 Accepted 0 Disapproved 7 Review Comments: f s. Massachusetts Department of Environmental Protection - Drinking Water Program B BACTERIOLOGICAL REPORT PANS ID#: 402Q022 , PWS Name: Great Marsh Htalth Services •CitylTown:� West Barnstable � Class: COM I � NTNC C z TNC n _ ;. ;, Cerf#<and certcflect,met�tads >, wt <l.l; ANA�YTdCAL lNt�� A'Cl��1 ;.Refer td aulr,MassDE,Psta,��tab certificate:far ra,;,,,r MA,,.,:; ,.: _ �.,,m'; `- Primary Lab MiA Cert#.: M-MA-t�Gi Primary La+� Name: Barnstable Ccunty,Hzalihi Department Lab � Subcontracted? (Y/N) � , Analysis Lab MA Cert#: Anaipsis Lab: _ • � � j I Original Report L� ReSUb pitted Report.`i Confirmation Report (1)Reason for Resubmission: [� Resample �� Reanalysis Report Correction (3)Collection Date of OrigmalSa.mPIP C TC Method E. Coli Method Fecal Coliforin I HPC Method i,µ'o�i� Lab Sample Notes. MF-SM9222B DEP APPROVED SAMPLE SITE INFORMATION COLT; ' COLLECTION< ANALYSIS I COTAL or CttL.t)RR HPG si ESUL A T[ME E RS 10000 Sink in Basement 0 4/17/2008 14:00 4/17/2008 16:38 Derek Ritchie 845820-01 r DEP Sample Type,Location Code#,and DEP Approved Sample Site Location must correspond to the sample information on your DEP Total Coliform Sampling Plan. z SWTR systems:HPC samples shall be taken at the same distribution sites,and at the same time as total coliform,whenever chlorine resival is not detected at the sample site. p,- 3 Sample Type:RS-RoutineDistribution Sample,RO-Original Site Repeat,UR-Upstream Repeat,DR-Downstream Repeat,AR—Additional Repeat,RW-Raw Water,PT-Plant Tap,SS-Special Sample.,!-. 4 Report as#/100 mL,P(present),A(Absent),or Too Numerous To Count TNTC-I(invalid)or TNTC-P(present). 5 Collect appropriate number of repeat samples within 24 hours of laboratory notification for coliform-positive or invalid`samples: Notify DEP of any routine or repeat E.Goli or fecal positive results by the end,of the,business day. Ea ertrfy un�erpanaltres aftaw chat tarn the person aufhorrtedfo fil/out[hi Corm a»dihe rnfnrmatron Laboratory authorized entr : accerrateandcofrrplefetofhebestofmy'krrowfdge signature and date: DEP Review Status: JEJ Accepted Disapproved Review Comments: Massachusetts Department of Environmental Protectidn,!= Drinking Water Program B —` BACTERIOLOGICAL REPORT r , , .., f: : .: f the PW,S Information,anal DEP rovedtiSam Ie,Sltelnformatlg,n sectonsbelow� �I. ,�,PW.S INFaORMATION, ,Refer to ourD�,,E�Cgli rorm�Sa_rnp �et„e�„ ,.�_,, .,.._�,___.. �.-._.,�..��, ��_JP -- �-,- PWS ID#> 4020022_I PWS Name: Great Marsh Health Services City/Town;: West Barnstable Class: COM ❑ NTNC ❑ TNC 91 11. ANALYTICALNFORMA ION Rsfe to .our MassDEP state lab certificatekfor rq er MA Cert#and certifledrmethofis _ Primary Lab MA Cek#: M-MA-009 Primary Lab Name: Barnstable County Health Department Lab Subcontracted? (Y/N) N y Analysis Lab MA Cert#: Analysis Lab: Q Original Report ❑ Resubmitted Report ❑ Confirmation Report (1)Reason for Resubmission: ❑.Resamplb ❑ Reanalysis ❑ Report Correction (2)Collection Date of Original Sample TC Method E. Col/ Method Fecal Coliform HPC Method MF-SM92226 Lab Sample Notes: d"5," x':`-s' `bk- $K`:.€t�#3 ix "" 'P.�. i:.a'� ' -�.UarS:?+•h _as W W ,� stow ' DEP APPROVED SAMPLE SITE INFORMATION t t 'E;COLI �� COLLECTIONS ANALYSISs d¢= Ni . _. ,.. ...r. � _.TOTAL. .... or �, CHLORINE w :... a f f .. x _., . ....x ,., _ u �,T.34.k.y,a.._,...�.,,.��:.t S,a.;.....au.:?CS....Dio.?1Ed7.-�uReF..#s.::�w�,4.�,._:..gC_...x,:e�„'>.:=,_:..-�y_....���._i.'.,-.,,,,.._..>.:..,a,t_�- .�._�,..,.....xi.m~,�-...>�..-.,:✓:�,;e"'w_..ma�,c �.,...-.._.��,,+.,:;.':��,,..-��. .h.s,,,.,.-.Y,.�Q,A,,�-s.(�C"_"__,-Q:..-.._..-LF,,I._F,�.O..:..R�..�M.,.s--....,:.FwE.C..._A,,a�...L�.,_..a,:.....:�,:,�,.-R,3�.E��vS+,�.t U..fs�'L'�,.T2.✓.r�.,.:�z 'tS , SAMRL 5Sam le.- et,3 T- I PPr ovoai e 'T ' ., ��M�•E::.....:��,�?;:.n.-DA�3y,T a,E,.�:�=...,,,,t�E.c.a„,,�a.: ._.�.T,. ,,ge-+��`y+,aF„:,M•�7 .,:;. r„ RS 10000 Sink in Basement 0 12/4/2007 08:45 12/4/2007 12:20 Derek Ritchie 744351-01 1 DEP Sample Type,_Location Code#;and DEP Approved Sample Site Location must correspond to the sample informatioh'on your DEP Total Coliform Sampling Plan. 2 SWTR systems:HPC samples,shall be taken at the same distribution sites,and at the same time as total coliform;:whenever chlorine resival is not detected at the sample site. 3 Sample Type:RS-RoutineDistribution Sample,RO-Original Site Repeat,UR-Upstream Repeat,DR-Downstream Repeat;AR Additional Repeat,RW-Raw Water,PT-Plant Tap,SS-Special Sample. 4 Report as#/100 mL,P(present);A(Absent),.or Too Numerous To Count TNTC-I(invalid)or TNTC-P(present): 5 Collect appropriate,numberof repeatsamples within 24 hours of laboratory notification for coliform-positive.or invalid samples. Notify DEP of any routine or repeat E.Coli or fecal positive results by the end of the business day. l certr�fyuriderpenaltresoflaw thatlam the person authorrzed to fill out this form and iheInformaUon },Laboratory authorized - M cpntafned,he{etn,lsarue �l�8C signature and date: DEP Review Status: ❑ Accepted Disapproved Review Comments: R Massachusetts Department of Environmental Protection - Drinking Water Program j BACTERIOLOGICAL REPORT 0 /` .. - .,. ..,•. .'..':.x' m "";�""", x'.,"z..;»eF�':�r "'S:7 a:...;a;.;:Y'y YK.�s.�. ..!r sr. I. PVUS,INFORMA. k.QN-:..,Refer,.to;your:MassD,EP.,C.olfform.Sam hn Rlanrto he corn lete the PWSrl iformatlonfiantl"MassDEP-:A r `p 9 ,z P „ ..,,. €,, =..u_ . , owed=Sample Slte lnformation sections:below. PWS ID 14020022 1 PWS Name: lGreat Marsh Health Services City/Town: lWest Barnstable Class: COM ❑ NTNC W TNC ❑ II. ANALYTICAL':INFORMATI Ri3fer to r µ. . i z.: . ..`.,O.N. _. .:our MassDEP State labkcertlfcate for roperiLab MA Cert#�anct_c�tfed method.s�,�,. Primary Lab MA Cert.#: M-MA009 Primary Lab Name: Barnstable County Health Department Lab Subcontracted? (Y/N)'', N❑ Analysis Lab MA Cert.#: Analysis Lab Name: 0 Original Report ❑ Resubmitted Report ❑ Confirmation Report (1)Reason for Resubmission: ❑ Resample ❑ Reanalysis ❑ Report Correction (2)Collection Date of Original Sample TotaL.Colrform E Colt„ _ Enterococcr f- - >;� Fecal Cohfo•: "' .V19fliwo �P:C(TC)reoan x ;, . tod eth � EPA 1604 MassDEP Approved Sample Site Information CQ"LLEGTION wANALYSIS' "� r, 3.: 28,4 S ya3.eatrz�;2A 'xs� 2t1r '' ,. _FC . a Results . Result . . �� .., hew CQ;LLECTED LAB SAMPLE'. Per .t{�:� __ �t#.*� x,..� y�-e ,} nv}�e roved:•SAMPL-EaLO.C'ATLO.N,,. . __• �.�i� ... ,., :: . pp., _. _ ATE T.ME DATE,:•,>yTIME.: ;T e.�,., _-Code#� r =:�W, � _.•. Result. ...,F,esult_� .Result ..Result.:.. m :L :� � - .:,:. ID'# • RS 10000 Sink in Basement A 9/4/2013 12:50 9/4/2013 17:02 Derek Ritchie 1376970-01 Sample Type,Location Code#,and Approved Sample Location must correspond to the sample information on your MassDEP Coliform Sampling Plan. 2A SWTR systems:HPC samples shall be taken at the same distribution sites,and at the same time as total coliform,whenever chlorine residual is not detected at the sample site. ZBFecal reporting is for unfiltered SWTR sources only 3 Sample Type:RS-Routine Distribution Sample,RO-Original Site Repeat,OR-Upstream Repeat,DR-Downstream Repeat,AR-Additional Repeat,RW-Raw Water,PT-Plant Tap,SS-Special Sample. 4 Report as#/100 mL,P(present),A(Absent),or Too Numerous To Count:TNTC-I(invalid)or TNTC-P(present). Notify MassDEP of any E.coli or enterococci positive results by the end of the business day: e Collect appropriate number of repeat samples wi thin 24 hours of laboratory notification for total coliform positive or invalid samples and E.coli or enterococci positive raw water samples. l ce , . � Laboratory authorized coin thebestdniomywdmtu 4 .`' /!!'C3✓ signature and date• DEP Review Status: ❑Accepted ❑ Disapproved Review Comments: P DEPARTMENT OF ENVIRONMENTAL PROTECTION >.BACTERIOLOGICAL ANALYSIS REPORT - CONTAMINANT ID#3100 PWSID#` PUBLIC WATER SYSTEM NAME ; TOWN/CITY LABORATORY NAME 6 ID#* 4020022' Great Marsh Chiropracfic West Barnstable Barnstable County Health M-MA009 SAMP LAB. .CODE# LOCATION .COLLECTION COLLECTION ANALYSIS DATE: TCM TOT COLIFORM/ FC/ECM FECAL - E.COLI/ CHLOR. RES or TYPE SAMP ID #. DATE TIME CODE# 100m1** CODE# 100m1+* HPC/ml SAMPLE COLLECTED BY: RS 40381 ACO Well #1 5/9/2007 10:11:00 5/9/2007 309 A - John Doriss FE-06- 5- 17007 t i SAMPLE TYPE KEY 'TOTAL COLIFORM FECAL COLIFORM/ REMARKS: METHOD(TCM) E. COLI METHOD - CODE # (FC/ECM) CODE # " RS- ROUTINE SAMPLE -- RO- ORIGINAL SITE REPEAT MF 3 0 3 EC 9 0 0 UR- UPSTREAM REPEAT DR- DOWNSTREAM REPEAT MTF 3 0 5 SWTR-MFC 4 0 1 - AR- ADD. REPEAT(DIST SYSTEM) raw water " RW- RAW WATER. ... P-A 3 0 7 SUBCONTRACTED FLAB (IF APPLICABLE). SS- SPECIAL. MMO-MUG 4 0 6 PT- PLANT TAP SAMPLE ONPG 3 0 9 ,. .. ... _ EC-MUG 9 0 8 ANALYZED BY:Alyssa'Fantaroni Date:S/ /2007 +*+ 3 1 1 (LAB USE) NA-MUG 9 - 1 0 AUTHORIZED BY: DATE: (LAB USE) * LAB ID# ASSIGNED BY STATE CERTIFICATION PROGRAM .. .. .. ** CAN BE EXPRESSED AS #/100ML,:, PRESENT(P), ABSENT(A), OR TOO NUMEROUS TO COUNT (TNTC)._'' +*+ COLI SURE;METHOD_ THIS-CAN DO TOTAL COLIFORM and E.COLI SIMULTANEOUSLY, HOWEVER THE:SAMPLE MUST"BE`INCUBATED 28 TO 98 HOURS. COPY 1: COPY TO DEP REGIONAL-"OFFICE; COPY 2: OWNER COPY; COPY 3: LAB COPY "`•-'"' "" -" "'" "' c1\co1xfrm2.frm 10/25/96 0 MASSACHUSETTS DEP/DIVISION OF WATER SUPPLY SOC SYNTHETIC ORGANIC CONTAMINANTS REPORT page 1 of 2 (FORM#9.3) I. PWS INFORMATION: 1. PWS ID# 4020022 2.City/Town: West Barnstable 3. PWS Name: Great Marsh Chiropractic 4. PWS Class(circle one): (COM), NTNC, NC 5.DEP Source Code/Location ID 6. Sample Location 7. Date Collected 8.Collected by ACO-FE-06-5-17007 Well#1 5/9/2007 John Doriss 9. Is the Source Treated? Y 10.Was the Sample Collected after Treatment? Y 11. Manifolded: [ ] If applicable,list the connected sources: Routine[X ] Special [ ] (explain below) Notes: Il. LABORATORY ANALYTICAL INFORMATION Lab Name: Barnstable County Health Lab Cert.#: MA009 Lab Symbol: BCL Subcontracted? (Y,N) Y Lab Sample ID#: 740381-01 (Use symbols to relate each analyte to a specific lab) Sub. Lab Name: Premier Laboratory,LLC Cert.#: M-CT008 Lab Symbol P Sub. Lab Name: Cert.#: Lab Symbol: Sub:.Lab Name:. Cert.#: .. Lab Symbol: Composite..[ ]. If.'applicable, list the.composited sources_(DEP Source.Code/Sample Location ID#) Notes.. ND;means Not Detected. "" 1 Compountl'Re'gulated Result MCL ; Detection Analytical Date. Oate; Lab` has MCL ug/L ug/L Limifug/L Method ".' Extracted, .._ An I'zed bol Carbofuran ND 40 0.90 EPA 531.2 5/1.7/4007 � Oxamyl ND 200 2.0 EPA 531.2 5/17/2 07 Ft 2,4-D ND 70 0.22 EPA 515.3 05/16/07 5/2a,/, °07 Pam`- ` 2,4,5-TP-Silvex ND 50 0.44 EPA 515.3 05/16/07 5/23d-'07 Pr- Dalapon ND 200 1.0 EPA 515.3 05/16/07 5/23O 7 P Dinoseb ND 7.0 0.44 EPA 515.3 05/16/07 5/2314 7 P U" Picloram ND 500 0.22 EPA 515.3 05/17/07 5/23/20 7 P W Alachlor ND 2.0 0.44 EPA 525.2 05/17/07 5/17/200 P C Atrazine ND 3.0 0.22 EPA 525.2 05/17/07 5/17/200 P Chlordane ND 2.0 0.20 EPA 505 05/16/07 5/17/200 P Endrin ND 2.0 0.022 EPA 525.2 05/17/07 5/17/2007 P Heptachlor NO 0.40 0.040 EPA 525.2 05/17/07 5/17/2007 P Heptachlor epoxide ND 0.20 0.044 EPA 525.2 05/17/07 5/17/2007 P Lindane ND 0.20 0.044 EPA 525.2 05/17/07 5/17/2007 P Methoxychlor ND," 40_ 0.22 EPA 525.2 05/17/07 5/1:7/2007'�- yP PCB.Aroclor 1016 ND - 0'22 " EPA,505 05/16/07 5/17/2007 P:, RCB Aroclor 1221:"• ND 022 EPA'505 "05%16>07 5/1-1/2007 P =V'• PCB'Aroclor 1'232 _- ND 0:22 -EPA 505 - 05/16/07. _.., . 5/.17/2007 P PCB Aroclor 1242 ND ---- 0.22 EPA 505 05/16/07 5/17/2007 P PCB Aroclor 1248 ND "' " --= -0.22 EPA 505 05/16/07 5/17/2007 P PCB Aroclor 1254 NO ---- 0.22 EPA 505 05/16/07 5/17/2007 P PCB Aroclor 1260 ND ---- 0.22 EPA 505 05/16/07 5/17/2007 P PCBs(decachlorobiphenyl) NO 0.50 0.5 EPA 508A 5/17/2007 P it z� MASSACHUSETTS DEP/DIVISION OF WATER SUPPLY SOC SYNTHETIC ORGANIC CONTAMINANTS REPORT page 2 of 2 PWS ID No 4020022 (FORM#9.3) Town: West Barnstable Sample Location Well#1 Compound:Regulated- Result MCL Detection Analytical Date Date Lab has MCL ug/L ug/L Limit ug/L Method Extracted Analyzed Symbol Pentachlorophenol ND 1.0 0.088 EPA 515.3 05/16/07 5/23/2007 P Toxaphene ND 3.0 .1.0 EPA 505 05/16/07 5/17/2007 P Benzo(a)pyrene ND 0.20 0.044 EPA 525.2 05/17/07 5/17/2007 P Di(2-ethylhexyl)adipate ND 400 0.60 EPA 525.2 05/17/07 5/17/2007 P Di(2-ethylhexyl)phthalates ND 6.0 1.3 EPA 525.2 05/17/07 5/17/2007 P Hexachlorobenzene NO 1.0" 0.10 EPA 525.2 05/17/07 5/17/2007 P Hexachlorocyclopentadiene ND 50 0.22 EPA 525.2 05/17/07 5/17/2007 P Simazine ND 4.0 0.15 EPA 525.2 05/17/07 5/17/2007 P Dibromochloropropane(DBCP)* NO 0.20 0.02 EPA 504.1 05/16/07 5/16/2007 BCH Ethylene dibromide (EDB)* ND 0,020 0.02 EPA 504.1 05/16/07 5/16/2007 BCH Diquat 20 Endothall 100 MONITORING FOR THESE COMPOUNDS HAS BEEN Glyphosate 700 WAIVED ON A STATEWIDE BASIS FOR BOTH 2,3,7,8 TCDD(Dioxin) 3x10 5 GROUND AND SURFACE WATER SOURCES.- Compound: Unregulated- Result Detection Analytical Date Date Lab no MCL ug/L Limit ug/L Method Extracted Analyzed Symbol Aldicarb(Temik) ND ` 0.50 EPA 531.2 5/17/2007 P Aldicarb Sulfoxide NO 0.50 EPA 531.2 5/17/2007 P Aldicarb Sulfone ND 0.80 EPA 531.2 5/17/2007 P Carbaryl ND 0.50 EPA 531.2 5/17/2007 P 3-Hydroxycarbofuran ND 0.50 EPA 531.2 5/17/2007 P Methomyl ND 0.50 EPA 531.2 5/17/2007 P Dicamba ND 0.22 EPA 515.3 05/16/07 5/23/2007 P Aldrin ND 0.10 EPA 525.2 05/17/07 5/17/2007 P Butachlor ND 0.10 EPA 525.2 05/17/07 5/17/2007 P Dieldrin ND 0.040 EPA 525.2 05/17/07 5/17/2007 P Metolachlor ND 0.10 EPA 525.2 05/17/07 5/17/2007 P Metribuzin ND 0.10 EPA 525.2 05/17/07 1 5/17/2007 P Propachlor ND 0.10 EPA 525.2 05/17/07 5/17/2007 P The QA/QC required matrix spike sample information is on file at our office. *Monitoring for these two compoundshas been waived on a statewide basis for SURFACE WATER SOURCES only. Unless specifically: requested by DEP,SURFACE WATER SOURCES do not have to monitor these compounds. **If you have been specifically instructed by DEP to monitor these compounds,please report them on a separate sheet. Laboratory Director Signature and Date: Attention: Mail two copies of this report to your DEP Regional Office within 30 days of receipt of results and no later than 10 days after the end of the reporting period. FOR DEP/DWS USE ONLY:PLEASE INITIAL AND DATE AS COMPLETED Accepted: Disapproved: Data Entered into WQTS: Comments: 4 MASSACHUSETTS DEP/DIVISION OF WATER SUPPLY SEC-CON page 1 of 2 SECONDARY CONTAMINANT REPORT (FORM #12.2) I. PWS INFORMATION: 1. PWS ID#4020022 2. City/Town:;West'Barnstable3 3. PWS Name: Great Marsh Chiropractic 4. PWS Class(circle one): COM, NTNC, NC 5. DEP Source Code/Location ID 6. Sample Location 7. Date Collected 8. Collected by A: ACO-FE-06-5-17007 Well#1 5/9/2007 John Doriss B. C: D: 9. Is the Source Treated? Y 10.Was the Sample Collected after Treatment? Y 11. Manifold[ ] If applicable, list the connected sources: Notes: II, LABORATORY ANALYTICAL INFORMATION: Lab Name: Barnstable County Health Lab Cert.#: M-MA009 Subcontracted? [ N J (use symbols to relate each analyte to a specific lab) Sub. Lab Name: Cert.# Lab Symbol: Notes: Analytical betection.. Date" A Method Limit. Analyzed Results m /L "' Lab. m /L A B C D Symbol Lab Sample ID ------------ -------- ------------- 740385-01 --------- Turbidity NTU EPA 180.1 0.20 5/9/2007 ND Conductivity,',umohs/cm EPA 120.1 1.0 5/9/2007 100 Color color units EPA 110.1 1.0 5/9/2007 ND --- Odor TON EPA 140.1 1 0 5/9/2007 ND ( IV -_ --- H EPA 150.1 5/9/2007 5.8 Alkalinity-Total CaCO3 SM 2320B 5.0 5/9/2007 15 'Y3 Hardness CaCO3 SM 2340B 0.10 5/10/2007 20 Calcium Ca SM 3111 B 0.10 5/10/2007 3.8CD Magnesium 'M SM 3111E 0.10 5/10/2007 2.5 --------- Aluminum AI EPA 200.8 0,001 5/10/2007 0.0077 Potassium K. SM 3111E 0.10 s 5/15/2007 1.6 -- ----- Iron Fe SM 3111E 0.10 5/15/2007 ND --------- Man anese Mn EPA 200.8 0.001 5/10/2007 0.011 Sulfate SO4j M'' EPA300.0 - 1.0 5/10/2007 7.3 ) k, t -- PWSID#: 4020022 (Form#12.2) Town: West Barnstable SEC-CON l page 2 of 2 Lab Sample ID#: 740385-01 Analytical Detection Date Method Limit Analyzed Results m /L Lab m /L A B C D S mbol Chloride(Cl) EPA 300.0 1.0 5/10/2007 12 --------- Silver(Ag) EPA 200.8 0.001 5/10/2007 ND Copper(Cu) SM 3111 B 0.10 5/15/2007 0.83 Zinc(Zn) SM 3111 B 0.01 5/15/2007 0.06 --—-- �,���Laboratory Director Signature and Date i Attention:Mail TWO copies of this report to our DEP Regional Office within 30 days of receipt of results and no later than 10 days after the end of the reporting period. FOR DEP/DWS USE ONLY: PLEASE INITIAL AND DATE AS COMPLETED Accepted: Disapproved: Data entered into WQTS: Comments: (p:\csocher\rep-frms.97\sec-cnl2.2, 10/15/96) , MASSACHUSETTS DEP/DIVISION OF WATER SUPPLY VOC VOLATILE ORGANIC CONTAMINANT REPORT page 1 of 3 (FORM#7.3) I PWS INFORMATION: 1. PWS ID#: 4020022 2. City/Town: West Barnstable 3. PWS Name: Great Marsh 4. PWS Class(circle one): COM, NTNC, NC 5. DEP Source Code/Location ID 6. Sample Location 7. Date Collected 8. Collected by ACO-FIE-06-5-17007 Well#1 1049 05/09/07 John Doriss 9. Is the Source Treated? N 10. Was the Sample Collected after Treatment? N 11. Manifolded: [ ] If applicable, list the connected sources: 12. Routine [ ] Special [ X J (explain below) Notes: II LABORATORY ANALYTICAL INFORMATION: Lab Name: Barnstable County Health Lab Cert.#: M-MA009 Subcontracted? (Y, N) N Lab Sample ID#: 740383-01 Sub. Lab Name: Cert.#: Lab Symbol: Composite: [ ] If applicable, list the composited sources(DEP Source Code/Sample Location): Notes: Compound (Regulated - Result MCL Detection Analytical Date has MCL) ug/L ug/L Limit ug/L Method Analyzed Benzene ND 5.0 0.50 EPA 524.2 5/9/2007 Carbon Tetrachloride ND 5.0 0.50 EPA 524.2 5/9/2007 1,1-Dichloroethylene ND 7.0 0.50 EPA 524.2 5/9/2007 1,2-Dichloroethahe ND 5.0 0.50 EPA 524.2 5/9/2007 para-Dichlorobenzene ND 5.0 0.50 EPA 524.2 5/9/2007 Trichloroethylene ND 5.0 0.50 EPA 524.2 5/9/2007 1,1,1-Trichloroethane ND 200.0 .0.50 EPA 524.2 5/9/2007 Vinyl Chloride ND 2.0 0.50 EPA 524.2 5/9/2007 Monochlorobenzene ND 100.0 0.50 EPA 524.2 5/9/2007 o-Dichlorobenzene ND 600.0 0.50 EPA 524.2 5/9/2007 trans-1,2-Dichloroethylene ND 100.0 0.50 EPA 524.2 5/9/2007 cis-1,2-Dichloroethylene ND 70.0 0.50 EPA 524.2 5/9/2007 1,2-Dichloropropane ND 5.0 0.50 EPA 524.2 5/9/2007 Ethylbenzene ND 700.0 0.50 EPA 524.2 5/9/2007 Styrene ND 100.0 0.50 EPA 524.2 5/9/2007 Tetrachloroeth lene ND 5.0 0.50 EPA 524.2 5/9/2007 Toluene ND 1000.0 0.50 EPA 524.2 5/9/2007 Xylenes (total) ND 10000.0 0.50 EPA 524.2 5/9/2007 Dichloromethane ND 5.0 0.50 EPA 524.2 5/9/2007 1,2;4-TrichlDrobenzene ND 70.0 0.50 EPA 524.2 5/9/2007 1,1;2=Trichloroethane - - ND ._ 5.01 0.50 . EPA 524.2_ 5/9/2007 < ..,. 1. _, ♦ ! . 1 Ill... i i ' r PWS ID No: 4096000 (FORM#7.3) Town: Falmouth VOC Page 2 of 3 Lab Sample ID#: 740383-01 Compound (Unregulated - Result Detection Analytical Date no MCL) ug/L Limit ug/L Method Analyzed Chloroform ND 0.50 EPA 524.2 5/9/2007 Bromodichloromethane ND 0.50 EPA 524.2 5/9/2007 Chlorodibromomethane ND 0.50 EPA 524.2 5/9/2007 Bromoform ND 0.50 EPA 524.2 5/9/2007 m-Dichlorobenzene ND 0.50 EPA 524.2 5/9/2007 Dibromomethane ND 0.50 EPA 524.2 5/9/2007 1,1-Dichloropropene ND 0.50 EPA 524.2 5/9/2007 1,1-Dichloroethane ND 0.50 EPA 524.2 5/9/2007 1,1,2,2-Tetrachloroethane ND 0.50 EPA 524.2 5/9/2007 1,3-Dichloropropane ND 0.50 EPA 524.2 5/9/2007 Chloromethane ND 0.50 EPA 524.2 5/9/2007 Bromomethane ND 0.50 EPA 524.2 5/9/2007 1,2,3-Trichloro ropane ND 0.50 EPA 524.2 5/9/2007 1,1,1,2-Tetrachloroethane ND 0.50 EPA 524.2 5/9/2007 Chloroethane ND 0.50 EPA 524.2 5/9/2007 2,2-Dichloropropane ND 0.50 EPA 524.2 5/9/2007 o-Chlorotoluene ND 0.50 EPA 524.2 5/9/2007 p-Chlorotoluene ND 0.50 EPA 524.2 5/9/2007 Bromobenzene ND 0.50 EPA 524.2 5/9/2007 1,3-Dichloropropene ND 0.50 EPA 524.2 5/9/2007 1,2,4-Trimethylbenzene t 0.50 EPA 524.2 5/9/2007 1,2,3-Trichlorobenzene 0.50 EPA 524.2 5/9/2007 n-Prop (benzene 0.50 EPA 524.2 5/9/2007 n-But (benzene ND 0.50 EPA 524.2 5/9/2007 Naphthalene ND 0.50 EPA 524.2 5/9/2007 Hexachlorobutadiene ND 0.50 EPA 524.2 5/9/2007 1,3,5-Tri methyl benzene ND 0.50 EPA 524.2 5/9/2007 p-Isoprop (toluene ND 0.50 EPA 524.2 5/9/2007 Isopropylbenzene ND 0.50 EPA 524.2 5/9/2007 tert-Butylbenzene ND 0.50 EPA 524.2 5/9/2007 PWS ID No: 4096000 (FORM#7.3) Town: Falmouth VOC Page 3 of 3 Lab Sample ID#: 740383-01 Compound (Unregulated - Result Detection Analytical Date no MCL) ug/L Limit ug/L Method Analyzed sec-Butylbenzene ND 0.50 EPA 524.2 5/9/2007 Fluorotrichloromethane ND 0.50 EPA 524.2 5/9/2007 Dichlorodifluoromethane ND 0.50 EPA 524.2 5/9/2007 Bromochloromethane ND 0.50 EPA 524.2 5/9/2007 Methyl tertiary Butyl Ether` ND 0.50 EPA 524.2 5/9/2007 ' optional Surrogate Recoveries (As required by EPA method 524.2) Compound % Recovered QC Limits (%) 4-Bromofluorobenzene 110 70-130 1,2-Dichlorobenzene-d4 1 93 70-130 The QA/QC required matrix spike sample information is on file at our office. Laboratory Director Signature and Date: Attention: Mail Two copies of this report to your DEP Regional O ce within 30 days of receipt of results and no later than 10 days after the end of the reporting period. FOR DEP/DWS USE ONLY: PLEASE INITIAL& DATE AS COMPLETED Accepted: Disapproved: I Data Entered into WQTS: Comments: (p:\csocher\rep-frms.97\voc7.3, 10/15/96) t COMMONWEALTH.OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION SOUTHEAST REGIONAL OFFICE . 20 RIVERSIDE DRIVE,LAKEVILLE,MA 02347 508-946-2700 MITT ROMNEY STEPHEN R.PRITCHARD Governor Secretary KERRY HEALEY ROBERT W.GOLLEDGE,Jr. Lieutenant Governor m >`� Commissioner - July 13,2006 Dr.John Doriss RE: BARNSTABLE--Public Water Supply Great Marsh Health Services Administrative Consent Order P.O.Box 122 Great Marsh Health Services West Barnstable,Massachusetts 02668 PWS ID#4020022 ACO-SE-06-5D007 Dear Dr.Doriss: Please find attached the following information: A signed original Administrative Consent Order for your records. Questions regarding the contents of the attached Order may be directed to Terry Martin;Department of Environmental Protection,20 Riverside Drive,Lakeville,Massachusetts,(508)946-2765. Ve truly yours, � ,r III David Y.Tei�'y - Deputy Regional Director Bureau of Resource Protection Tn7&cb ''�_, Tmartin/ACOcoverfina106greatmarsh.doc ) YADWP Archive\SERO\Barnstable-40200022-Enforcement-2006-07-13 CERTIFIED MAIL NO.70041350 0004 4566 1334 } This information is available in alternate format.Call Donald M.Gomes,ADA Coordinator at 617-556-1057.TDD Service-1-800-298-2207. MassDEP on the World Wide Web: http://www.mass.gov/dep �� Printed on Recycled Paper I 2 e_cc: DEP/SERO cc: DEP-SERO Shaun Walsh Regional Enforcement Office Theresa Barao . Rich Gioiosa Lee MacEachern Brad Lacouture cc: Barnstable Board of Health COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRO NMENTAL NMENT AL AFF AIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION In the matter of: ) Great Marsh Health Services ) ACO-SE-06-5D007 West Barnstable ) ADMINISTRATIVE CONSENT ORDER I. THE PARTIES I. The Massachusetts Department of Environmental Protection("MassDEP") is a duly { constituted agency of the Commonwealth of Massachusetts established pursuant to M.G.L. c. 21A, §7. MassDEP maintains its principal office at One Winter Street, Boston, Massachusetts 02108, and its Southeast Regional Office at 20 Riverside.Drive, Lakeville, Massachusetts 02347. 2. The Great Marsh Chiropractic Clinic, Inc. (the "Respondent") is'a corporation with a place of business known as Great Marsh Health Services, at 1049 Main Street(Route 6A), West Barnstable,Massachusetts. The mailing address for the Respondent is P.O. Box 122, West Barnstable,Massachusetts, 02668. The Respondent operates a chiropractic facility and professional office space at 1049 Main Street(Route 6A). II. STATEMENT OF FACTS AND LAW 3. MassDEP is responsible for the implementation and enforcement of M.G.L c. 111, § 159 et seq., 42 U.S.C. § 300f-300j (the Federal Safe Drinking Water Act),the Drinking Water Regulations at 310 CMR 22.00;the Cross Connections, Distribution System Protection Regulations at 310 CMR 22.22; and the Underground Injection Control Regulations at 310 CMR 27.00. MassDEP has authority under M.G.L. c. 21A, §16, and the Administrative Penalty Regulations at 310 CMR 5.00,to assess civil administrative penalties to persons in noncompliance with the laws and regulations set forth above. 4. Respondent'is operating an unapproved public water,supply,pursuant to 310 CMR 22.00. In the Matter of Great Marsh Health Services ACO-SE-06-5D007 _ Page 2 of 7 5. The following facts and alleged violations have led MassDEP to issue this Consent Order: ...........- A. The Respondent operates a chiropractic facility and professional office space-at the Site. By providing water to an average of at least 25 individuals daily at least 60 days of the year,the Respondent owns and operates a public water system as that term is defined in the Drinking Water Regulations at 310 CMR 22.02. B. The Respondent's public water system has never received approval from MassDEP, in violation of 310 CMR 22.03(1) and 310 CMR 22.04(1). C. During a Site inspection on September 8, 2005, a MassDEP representative observed that the Respondent does not own or control the Zone I of its water supply well, in violation of 310 CMR 22.21(3)(b), because a road(Route 6A)is located within the Zone I. In addition, the MassDEP representative observed the following non-water supply related activities within the Zone I of its well, in violation of 310 CMR 22.21(3)(b): buildings, driving ways and parking areas. 6. On April 27, 2006,the Respondent met with representatives of MassDEP relative to the noncompliance matters identified in this document. III. DISPOSITION AND ORDER For the reasons set forth above,MassDEP hereby issues, and the Respondent hereby consents to, the following Order: 7. The parties have agreed to enter into this Consent Order because they agree that it is in their own interests, and in the public interest,to proceed promptly with the actions called for herein rather than to expend additional time and resources litigating the matters set forth above. Respondent enters into this Consent Order without admitting or denying the facts or allegations set forth herein. However,Respondent agrees not to contest such facts and allegations for the purposes of the issuance or enforcement of this Consent Order. 8. MassDEP's authority to issue this Consent Order is conferred by the Statutes and Regulations cited in Part II of this Consent Order. 9. The Respondent shall operate its transient,non-community public water supply under.PWS ID #4020022 and shall take the following actions: A. Within ninety(90) days of the effective date of this Consent Order,the Respondent shall: 1. Sample the existing well for contaminants listed in the 2001 Guidelines and Policies for Public Water Systems - Appendix A- Water Quality Testing Requirements and report the results to MassDEP immediately upon receipt. In the Matter of Great Marsh Health Services ACO-SE-06-5D007 Page 3 of 7 Contaminant testing shall include the following categories: bacteria, inorganic compounds,volatile organic compounds, secondary contaminants,radionuclides (including gross alpha,radium 226,radium 228,uranium and radon). The testing shall be performed by-;!'Massachusetts certified laboratory using approved methodology for each potable water contaminant, and the results submitted on MassDEP water quality monitoring forms. The Respondent shall thereafter sample water according to the protocols and sampling schedule that will be issued by MassDEP after review of the initial sampling results. 2. In accordance with 310 CMR 22.11B, obtain a public water supply certified operator of the appropriate grade and forward a copy of the contract(MassDEP Certified_Operator Compliance Notice)to MassDEP for review and approval. _ The Respondent shall thereafter retain a certified water supply operator to operate the public water supply system at the Facility at all times in compliance with the Drinking Water Regulations. As an alternative,the system may apply to the Board of Registration for temporary emergency certification to allow on-site personnel to become certified within the prescribed time frame. The Department must be notified if emergency certification is sought. 3. Submit a"Colifor n Sampling Plan"for MassDEP approval. 4. Complete and submit the "Cross Connection Program Plan," "Request for Authorization to Delegate, Subdelegate, Contract Or Subcontract Cross Connection Responsibilities for Surveyors." 5. Have a cross connection survey conducted on the water system by a Massachusetts certified cross connection surveyor and submit a cross connection inspection report to MassDEP. 6. Install any cross connection control devices as identified by the cross connection surveyor: 7. Install a water meter on the source, and record monthly water use on the Annual Statistical Report form. 8. Provide to MassDEP the construction specifications of the well (well depth,pump depth, screen length etc.), if available. 9. Record an Affidavit of Public Water Supply Status in the Registry of Deeds. (Appendix B of the Guidelines &Policies for Public Water Systems) and provide MassDEP with a copy of said Affidavit with the recording information thereon. B. The Respondent shall not increase water usage without prior written approval of MassDEP. In the Matter of Great Marsh Health Services ACO-SE-06-5D"007 _. . Page 4.of 7 10. Except as otherwise provided, all notices, submittals and other communication required by this Consent Order shall be directed to: Terry Martin;Environmental Analyst Massachusetts Department of Environmental Protection 20 Riverside Drive Lakeville,Massachusetts 02347 Such notices, submittals and other communications shall be considered delivered by Respondent upon receipt by the Department. 11. Actions required by this Consent Order shall be taken in accordance with.all,applicable federal, state, and local laws, regulations and approvals. This Consent Order shall not be construed as, nor operate as, relieving the Respondent or any other person of the necessity of complying with all applicable federal, state, and local laws,regulations and approvals. 12. For purposes of M.G.L. c. 21A, §16 and 31D CMR 5.00, this Consent Order shall serve as a Notice of Noncompliance for the Respondent's noncompliance with the requirements cited in Part II above. MassDEP hereby determines, and the Respondent hereby agrees, that the deadlines set forth above constitute reasonable periods of time for the Respondent to take the actions described. 13. The Respondent understands and hereby waives its right to an adjudicatory hearing before MassDEP on, and judicial review of, the issuance and terms of this Consent Order and to notice of any such rights of review. This waiver does not extend to any other order issued by MassDEP. 14. This Consent Order may be modified only by written agreement of the parties hereto. 15. The provisions of this Consent Order are severable, and if any provision of this Consent Order, or the application thereof, is held invalid, such invalidity shall not affect the validity of other provisions of this Consent Order, or the application of such other provisions, which can be given effect without the invalid provision or application; provided,however,that MassDEP shall have the discretion to void this Consent Order in the event of any such invalidity. 16. Nothing in this Consent Order shall be construed or operate as barring, diminishing, adjudicating or in any affecting (i)_any legal or equitable right of:MassDEP to issue any additional Order or to seek any other relief with respect to the subject matter covered by this Consent Order, or(ii) any legal or equitable right of MassDEP to pursue any other claim, action, suit, cause of action, or demand which MassDEP may have with respect to the subject matter covered by this Consent Order, including, without limitation, any action to enforce this Consent Order in an administrative or judicial proceeding. Nu thstandirigtlie-foregoing, MassDEP agrees that it will not seek to assess the_ r In the Matter of Great Marsh Health Services ACO-SE-06-5D007 Page 5 of 7 Respondent civil administrative penalties beyond those described in this Consent Order for the violations identified in Part II above,provided that the Respondent substantially satisfies the terms and conditions of this Consent Order and any approval issued hereunder: 17. This Consent Order shall not be construed or operate as barring, diminishing, adjudicating, or in any way affecting, any legal or equitable right of MassDEP with respect to any subject matter not covered by this Consent Order. 18. This Consent Order shall be binding upon the Respondent and upon Respondent's heirs, successors and assigns. Respondent shall not violate this Consent Order and shall not allow or suffer Respondent's directors, officers; employees, agents, contractors or consultants to violate this Consent Order. Until Respondent has fully complied with this Consent Order,Respondent shall provide a copy of this Consent Order to each successor or assignee at such time that any succession or assignment occurs. 19. Respondent shall pay stipulated civil administrative penalties to the Commonwealth in accordance with the following schedule if the Respondent violates any provision of this Consent Order: For each day, or portion thereof, of each violation,the Respondent shall pay stipulated civil administrative penalties to the Commonwealth as follows: Period of Violation Penally per day l't through 15th day $ 100.00 per day 16th through 30th day $ 500.00 per day 31 st day and thereafter $1000.00 per day Stipulated civil administrative penalties shall begin to accrue on the day a violation occurs and shall continue to accrue until the day the Respondent corrects the violation or completes performance, whichever is applicable. Stipulated civil administrative penalties shall accrue regardless of whether MdgsDEP has notified the Respondent of a violation or act of noncompliance. All stipulated civil administrative penalties accruing under this Consent Order shall be paid within thirty(30) days of the date MassDEP sends the Respondent a written demand for payment. If a court judgment is necessary to execute a claim for stipulated penalties under this Consent Order,Respondent agrees to assent to the entry of such judgment. If simultaneous violations occur, separate penalties shall accrue for separate violations of this Consent Order. The payment of stipulated civil administrative penalties shall not alter in any way the Respondent's obligation to complete performance as required by this Consent Order. MassDEP'reserves its right to... elect to pursue alternative remedies and alternative civil and criminal penalties which may be available by reason of the Respondent's failure to comply with the requirements of this Consent Order. In the event the Department collects alternative civil administrative penalties, Respondent shall not be required to pay stipulated civil administrative penalties pursuant to this Consent Order for the same violations. In the Matter of Great Marsh Health Services ACO-SE-06-5D007 Page 6 of 7 Respondent reserves whatever rights it may have to contest the Department's determination that Respondent failed to comply with the Consent Order and/or to contest the accuracy of the Department's calculation of.the amount of the stipulated civil administrative penalty. - 20. The Respondent shall pay all civil administrative penalties due under this Consent Order, including suspended and/or stipulated penalties,by certified check, cashier's check, or money order payable to the Commonwealth of Massachusetts. The Respondent shall clearly print on the face of its payment the Respondent's full name,the file number appearing on the first page of this Consent Order ACO-SE-06-5D007, and the Respondent's Federal Employer Identification Number, and shall mail it to: Massachusetts Department of Environmental Protection Commonwealth Master Lockbox P.O. Box 3982 Boston,Massachusetts 02241-3982 The Respondent shall simultaneously mail a copy of the payment to: David Y. Terry, Deputy Regional Director Massachusetts Department of Environmental Protection 20 Riverside Drive Lakeville,Massachusetts 02347 In the event the Respondent fails to pay in full, any civil administrative penalty as required by this Consent Order,then pursuant to M.G.L. c. 21A, § 16,Respondent shall be liable to the Commonwealth for up to three (3)times the amount of the civil administrative penalty,together with costs,plus interest on the balance due from the time such penalty became due and attorneys' fees, including all costs and attorneys' fees incurred in the collection thereof. The rate of interest shall be the rate set forth in M.G.L. c. 231, §6C. The Respondent shall not be deemed to have returned to compliance'until the Respondent pays all penalties due under this Consent Order and takes all actions required by this Consent Order. 21. Failure on the part of MassDEP to complain of any action or inaction on the part of Respondent shall not constitute a waiver by MassDEP of any of its rights under this Consent Order.Further,no waiver by the Department of any provision of this Consent Order shall be construed as a waiver of any other provision of this Consent Order. 22. The Respondent agrees to provide MassDEP, and MassDEP's employees, representatives and contractors, access at all reasonable times to the Facility for purposes of conducting any activity related to its oversight of this Consent Order. Notwithstanding any provisions of this Consent Order,MassDEP retains all of its access authorities and rights under applicable state and federal law. Y L Y . In the Matter of Great Marsh Health Services ACO-SE-06-5D007 Page 7 of 7 23. The undersigned'representatives certify that they are fully authorized to enter into the terms and conditions of this Consent Order and to legally bind the parties that they represent. 24. This Consent Order shall become effective on the date that it is executed by MassDEP. GREAT MARSH CHIROPRACT _ CLINIC, INC. i By: Date: ohn ss,President Great Marsh Chiropractic Clinic, Inc. P.O. Box 122 1663 Main Street West Barnstable,Massachusetts 02668 Federal Employer Identification No. 042655643 MASSACHUSIATTS DEPARTMENT OF ENVIRONMENTAL PROTECTION By: Date: �6 Gai.S. M ran,Regional irector Sou ast egional Office - 20 Rive 'de Drive Lakeville,Massachusetts 02347 Telephone: (508) 946-2712 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Drinking Water Program l Aje--Fs N TRANSIENT NON-COMMUNITY(TNC) VIOLATION ' NOTICE OF NONCOMPLIANCE (NON) Enforcement Notice: M.G.L. c.21A sec. 16,310 CMR'5.00 Attention: Owner/Owner representative/Responsible party: NON - BO - 10 - 5D102 ` General Information PWS NAME: GREAT MARSH CHIROPRACTIC DATE: 12/1/2010 P.O.BOX 122 PWSID: 4020022 CLASS: NC WEST BARNSTABLE MA 02668 CITYITOWN: WEST BARNSTABLE ff-Location•Where Noncompliance Occurred: GREAT MARSH HEALTH SERVICES Description of Violations under M.G.L. c. 111 sec. 159-160 and 310 CMR 22.00 and Corrective Actions to Take and Deadlines for Taking Such Actions: 1. The Department of Environmental Protection(MassDEP), Drinking Water Program(DWP), records indicate that your system is in violation of the following checked(X)requirements. In order to return to compliance your system must take the corrective action(s)by the prescribed deadline(s): Descr'ipUon o ju�rew f 1/rolabonAy eid Corrective Actron an"tl Deadlrne for Takrng?Such Acton„ „� £ , R Within 30 days of receiving this NON You must complete,sign and submit an electronic Annual Statistical Report,via eDEP. Detailed instructions are available at http://www.mass.gov/dep/water/approvals/dwsforms.htm#statrep.You must also complete Failure to submit the 2009 and submit the attached TNC Violation Response Form to MassDEP/DWP, 1 Winter Street,5th Floor, X Annual Statistical Report to Boston, MA 02108,Attention: Tio Yano. the Department, as requried Or by310CMR22.15; You must complete,sign and submit the paper Annual Statistical Report that was mailed to you following your submittal of a Hardship Application Form along with a completed Violation Response Form to MassDEP/DWP,, 1 Winter Street,5th Floor,Boston,MA 02108,Attention: Tio Yano. Within 30 days of receiving this NON You must contract for the services of a Massachusetts certified operator of the required grade and submit the attached Public Water System Certified Operator Compliance Notice along with a completed Violation Response Form to MassDEP/DWP, 1 Winter Street,5th Floor,Boston,MA 02108,Attention:,Tio Yano. Operating a public water Or system without a-certified a You must apply to the Board of Certification of Operators of Drinking Water Supply Facilities for a temporary opetator;as required by 310 six-month emergency certification*and submit a copy of the completed application along with a completed CMR 2211 B(1)&,, Violation Response Form to MassDEP/DWP, 1 Winter Street,5th Floor, Boston,MA 02108,Attention: Tio I---: Yano. �rr7 6 r ti In addition,within 6 months of receiving this NON Your system must be operated by personnel that �., fulfill the certified operator requirements as stated in 310 CMR 22.11E(1)and(2). U_ i - t �'.': *To apply for a temporary six-month emergency certification you must completely fill out and mail the attached Temporary Emergency Certification Application along with the required fee, to the Board at 1000 Washington Street, Suite 710, Boston, MA 0211876100. Failure t submit a cross Within 30 days of receiving this NON You must complete and submit the attached Cross Connection connection control program plan Control Program Plan Questionaire for TNC Public Water Systems and submit 2 copies along with a to the Department,as requried completed TNC Violation Response Form to MassDEP/DWP, 1 Winter Street,5th Floor, Boston,MA 02108, by 310 CMR 22.22(3); Attention: Tio Yano. .2. If your system HAS COMPLIED with any or all of the requirements listed and checked(X)above,you must submit proof. Examples of proof include copies of return receipt postcards from the post office postmarked prior to the deadline(s).You must submit the proof and 2 copies of the required information along with a completed Violation Response Form to MassDEP/DWP, 1 Winter Street,5th Floor, Boston, MA 02108,Attention Tio Yano. ID important Information An administrative penalty may be assessed for every day from now on that you are in noncompliance with the requirements described in this NON. Notwithstanding this NON,the Department reserves the right to exercise the full extent of its legal authority in order to obtain full compliance with all applicable requirements including,but'not limited to, criminal prosecution, civil action, including court-imposed civil penalties or administrative penalties assessed by the Department. If you h6v�e any questions about.this NON.please'call Tio Yano at 617-292-5843. Certified Mail#; 103 :�i(D W 60 93 Date Mailed: Attachments cc: MassDEP Boston-Office of Enforcement Dave Terry, Program Director MassDEP Regional Office-DWP Drinking Water Program Local BOH Bureau of Resource Protection/MassDEP 0 Certified Operator Massachusetts Department of Environmental Protection Bureau of Resource Protection -Drinking Water Program Z F TRANSIENT NON-COMMUNITY VIOLATION RESPONSE FORM (TNCVRF) M.G.L. c.21A sec. 16,310 CMR 5.00 Attention: MassDEP/Drinking Water Program General Information DATE; 12/1/2010 PWS NAME: GREAT MARSH CHIROPRACTIC. RE: NON - BO- 10 - 5D102 P.O. BOX 122 PWSID: 4020022 CLASS: NC WEST BARNSTABLE MA 02668 CITY/TOWN: WEST BARNSTABLE Location Where Noncompliance Occurred. GREAT MARSH HEALTH SERVICES Description of Corrective Action Taken underM:G.L. c. 111 sec. 159-160 and 310 CMR 22.00: My public water system has.taken the following actions to correct the violations listed in the above referenced NON.(please check all that apply) Descnpfron of Violafrony& on o Descripti of Correcfroe'Actins Taken,b the Pubhc Water System f 3 „ 4 r .,,.. ❑ My system DID submit the 2009 Annual Statistical report to MassDEP by the required deadline Within 30 days of receiving the above referenced NON I am submitting this form and a copy of the eDEP Failure to submit the 2009 Annual receipt that proves that my system submitted this report by the deadline. Statistical report to the ❑ .My system DID NOT submit the 2009 Annual Statistical report. Within 30 days of receiving the above Department,as requried by 310 CMR 22.15; referenced NON I am submitting this form and(select one): ❑ I will complete,sign and submit an electronic Annual Statistical Report via eDEP ❑ I will complete,sign and submit the paper Annual Statistical Report previously mailed to me. ❑ My system HAS the required Certified Operator and DID report to the MassDEP this change in operator status as required. Within 30 days of receiving the above referenced NON I am submitting proof that my system has the required Certified Operator and had properly notified the Department. See attached photocopies of the license(s),contract(s)and other supporting documentation that proves my system submitted this information by the deadline. I have completed the Certified Operator Status Table below. ❑ My system HAS the required Certified Operator but DID NOT"report to the MassDEP any changes in operator status as required. Within 30 days of receiving the above referenced NON I"am submitting proof that my Operating a public water system system has the required Certified Operator. See attached photocopies of the license(s)and contract(s). I have without a certified operator as completed the Certified Operator Status Table below. required by 310 CMR 22.11 B(1); ❑ My system DID NOT have the required Certified Operator. Within 30 days of receiving the above referenced NON my system has(select one): ❑ Obtained the services of a Certified Operator of the required.certification grade and completed and submitted a Public Water System-Certified Operator Compliance Notice form to the Board for verification and signature.See attached copy of the completed form. I have completed the Certified Operator Status Table below. ❑ Applied to the Board for a temporary six-month emergency certification(copy attached). 1 understand that within six months of receipt of the above referenced NON my system must be operated by personnel that fulfill the certirred operator requirement as stated in 310 CMR 22.11E(1)and(2). ❑ I will report all future changes in my system's Certified Operator status to DEP within 24 hours of such changes. I will also provide MassDEP with written documentation of the change within 30 days. ❑ My system DID submit a Cross Connection Control Program(CCCP)Plan to DER by the required deadline. Failure to submit a cross- Within 30 days of receiving the above referenced NON I am submiting this form,two(2)copies of the connection control program plan to completed CCCP Plan Questionaire for TNC Public Water Systems and documentation that proves that my the Department,as requried by 310 CMR 22.22(3); system submitted this report by the deadline. ❑ My system DID NOT submit a Cross Connection Control Program(CCCP)Plan. Within 30 days of receiving the above referenced NON I am submitting this form and two(2)copies of the completed CCCP Plan. ❑ My system was unable to meet some or all of the corrective action requirements identified in the above referenced NON.An explanation is attached. I understand that I may be subject to further enforcement action. Cedified rOpe�ra#or Status Table t' Name/Address/Phone# Licence# Grade Approximate dates of planned routine monthly site inspection Certified Operator Owner,Owner Representative,Water Commissioner or other Responsible Party Print Name: Title: Phone#.: ( ) Signature: Date: Email address cc:MassDEP/DWP Regional Office, Local Board of Health Please complete and return this response form to:.MassDEP/DWP,1 Winter Street,5th Floor, Boston,MA 02108,Attention:Tio Yano, Massachusetts Department of Environmental Protection - Drinking Water Program. N Nitrate Report �%�� 41-0 � . PWS INFORMATION Please refer to your fat=P CNater Qualrty Sampling Schedule tU1/QSS}to ftelp complete ktus form PWS ID#: !14020022. • --City]Town: �11\/Vest Barnstable -- - PWS•Name Great Marsh Health ervrc COM•❑ C ❑ S es — — — - ass: NTN � TN• < x s t DEP LOCATION: Sample Dat@ C DEP tocatlon Nam@ Sample Information otlect@tl By (LOC}1D# gcitlifietl� Coll@cted': A 10000 Sink in Basement of 1049 Rt.6A (M)ultiple d (R)aw 0 (S)ingle El (F)inished Yes ❑ 7/16/2008 Derek Ritchie B ❑ (M)ultiple ❑ (R)aw Yes ❑ ❑ (S)ingle ❑ (F)inished C ❑ (M)ultiple ❑ (R)aw Yes ❑ ❑ (S)ingle ❑ Finished p ❑ (M)ultiple ❑ (R)aw Yes El (S)ingle ❑ (F)inished Routine or Orfgnaf,R@Subrnitir33 or t PERMIf Resubrrt[tted Re ort list•,betow Spectal Samrile Confirmation Rr�oort ) /11 Raacc+n#Rr R�@"�Mr= ter} ',rat n r�a;w r eM r ..*r � a n «` A Q RS ❑ SS ❑V] Original ❑ Resubmitted ❑ Confirmation Resample❑ Reanalysis ❑ Report Correction B In RS ❑ SS ❑ Original ❑ Resubmitted ❑ Confirmation 7 Resample❑ Reanalysis .❑ Report Correction ry ❑ RS ❑ SS ❑ Original ❑ Resubmitted ❑ Confirmation Resample❑ Reanalysis ❑ Report Correction C= D ❑ RS ❑ SS ❑ Original ❑ Resubmitted. ❑ Confirmation Resample❑ Reanalysis ❑ Report Correction SAMP:`LE NOTi=S (5uch as, tNanffold/MultIpte samp}e,Irst tk a sources that were on tm tluring.samp[e colfecUor;} M 1 A cagy j OD B m —v a D I1 AWAI Y1"tCA�..C�AE30R4TOR'Y INFORAlIAT10N; . ,.. - y Prima Lab MA Cert# W MA009 I Prima Lab Name: Barnstable Count Health Lab Subcontracted. Y/N N Primary ry. Analysis Lab MA.Cert# Analysis Lab Name: -� NITRATE MGL IVI[)L r Lab Lab Method Dat@ analyz@d Result(mglC (mg1L} (mgCL7 Sampl@ Iq# MEN mom A 0.93 1p 0.10 EPA 300.0 7/16/2008 847841-01 B "10 - C Finished water results equal to or exceeding 1/2 of the M.CL(5 mg/L)triggers quaiteriy monitoring. Finished water result,exceeding'he PlICL of 10 rng/L requires confirmation sampling within 24 hours, Notify MassDEP of any MCL exceedances. LAI3 SAMPLE'NOYES l oerirfy una6%paaalt s:oflawthat l din the parson Primary Lab Director Signature=--`__/� a dhunzed fu fi/i cut tf rs f rrn an"f fbe rfwnratrun uor arrrerr ni f rs Date: V 1� i.a acr crratarand ca rf /ate to t'ie Feast e<Cent ar my tnow!edge '7 ¢ t - —_� If not submitting these results e/echonically,mail TWO copies of this report to your DEP Regional Office no later than 10 days after the end of the month in which you receive: this report or no later than 1�days after the end of the reporting period:whichever is sooner. 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R fer�tf your-DEP oliforrt�am Itnc Planto hel 3com. te;thegPWStln.formatton and DEP A •roved Sam le�telnforma=tlo.n•se•tl- : PWS ID#: 4Q2a022,`� PV1/S Nam Great Marsh Health Services City/Tovvn West Barnstable Class: COM ❑ NTNC RI TNC ❑ .... � E-5;* sxw xs+;aara,,:.ry �nr °Y' ;•�^sro'xa^ .S" <, },�""x^":•"�fi. .„ - .+ a �§5;:. , tar , ..,, .=a M -' U"Er.�`� "€twrzxi".,,..'.,, c YItANAL-YtaICr�L IP,iF®RMAxT10N�i�efet.t�, our"?NlassD�-P,state lab�certlftcatefor� ro er MA Cert�#+and c�ettfted etheicls + ,*. �>�� .,-:,.�.o�_�•s..o .,.uk:o,�.?.�✓ xa.ta �....,_ ,,,.. .�..,,_�1..�.. a. ,�r.,a�«,.>r.,,z - ...-....n.,,...�t .�., nE: ...M�,,........,... ., at,,...,.•_...,,.,.. -....,,..-.,.,.: � �,. .. � '. , �:'' Primary'Lab MA`Cert# _ M-;MA-'009 Pr man/ Lab Name: Barnstable County Health Department Lab Subcontracted? (YIN) Analysis Lab MA Cert#: I Analysis Lab: Original Report �;' Resubmitted Report Confirmation Report (1)Reason for Resubmission.' ❑.Resample, ;❑ Reanalysis ❑ Report Correction (2)Collection Date of Original Sample r�J TC Method E. Coli Method Fecal Coliform HPC Method. MF-Siv19222B Lab Sample;Notes: - p -"- INFORMATION ta.«''�. a ;,--.ejt2. x., > , : 'w � G_„> h..;�. a�..j;.,L DEP AP ROVED SAMPLE SITE,NFORMATIOP� g cop ¢Y �' r ,FT' COLLECTION "*, ? `ANALYSIS z .. ,v,,•wsa`." ": to r c` ,;x ,.cx.r �4: -kY,•; a+..z::^.?,�.3a ly:C�ti. n4xx n ..�b .:x...c.• ,: .cf` >,;,'t ash.....'.,-� ..a- _ Y9,t, d n k , _. H x LAB;:. : . .... x. n.. .m:: •x ,.. s _ _> _ _.� ,.._ _ � _..TOTAL ._ or. :. �CHLO.RINE �__}},HPC „ :. ram..,. �� , 3,� 3. ,. - .-. ».c'._.. v.... - ,.�v ,,..'.s .'f,.F_. 3' -_... ..- ,..-..... .._ _ .,.. , vte ,¢S `at _.,Y.rZ".r.,.F-.�,. 'i.t'M1n.'....,.. .,; ,., 7!"r. ."�' �, 4¢ t :'d _,,..DEP... �:h ... �.ice.. � } zx <rx. x r..,z.,r ,..,� �,�.>.. :, .DEP :�„ ., s=•... ,,.; .�.� �.'< �,>,� _� .. '�., =;SAMPLE RESULT €..,., ,_, ,., �..,-.: a-.�k...,,.,. y G q x >• - <" x 1.+.. QS r $ tx .,. �" L... ". a :, . :?: .,,> ,. roved,Sam Ie.Location_,:., . .,:r ,; ,, . ,§,. _ f x. ,,B ., ..,:�.. ,..RESULT....£,RESULT` -��m /L,<- x .#>cfu/.mL � ., �.., -.. �.. �. >. .. DATE rTIME DATE TIME .COLLEGTE•D BY > •._.:L ol,.!,- -&�,..., lf �r .ti E ._z y ..<.. ..4o x ,,�. �}�x k-� ... '3 .. - ...c__. .r.. ..�..:...�� ..�t.. Mz�:' -�.�.-'�:,;,.C9.�&t ,.':a.:�i4 ,'f-`4r+-:�"li, <�.�`�"'�a`,hr:.:tar.�'�`a•�':.:'6:4�-as,`.n ��F:. RS 10000 Sink in.Basement of 1049 Rt.6A 0 �; ?:, . 7/16/2008 10:00 7/16/2008 11:51 Derek Ritchie' 847840-01 r DEP Sampte Type;_Location Code#,and DEP Approved Sample Site Location must correspond to the sample.information.bn your DEP Total Coliform Sampling Plan. 2 SWTR systems:-FIEC samples siiall be taken at the same distribution sites,and at thq same time as total coliform,.whenever-chlorine resival is not detected at the sample site. 3 Sample Type:RS-RoutineDistribution Sample,RO-Original Site Repeal,UR-U stream Repeat,DR-Downstream Re"peat,AR-Additional Repeat,RW Raw Water,PT-Plant Tap,SS-Special Sample. Q Report as#/100 ml:;P(present),A(Absent),or Too Numerous To Courit TNTC-1(invalid)or TNTC-P(present).:,wz: 1 - Collect appropriate numberofrepeat samples within 24 hours of laboratory notification for coliform-positive'or;invalidisaYnples.t:Notify DEP of any routine or repeat E.Coli or fecal positive results by the end of the business day. !u rVfy under<penalt�res of+law that I am the person authorized;o h!I out th(s form and the rnformafron '� ,Laborato authorized signatu contarned herern i3 t ue a'curate and complete 10 the tiesf of my knot rledge` �, h.� �' r�+E x �+ - r!Y ,r _.... .. .. _.. .. .. �_, .,_..�. . ... ,.. re and date: I DEP Review States: I�Accepted Disapproved Review Comments: t L_ :lM4ssachusetts'Department of Environmental,Protection, Drinking Water Program B BACTERIOLOGICAL REPORT "J(�. a KO x .. ...,-.,,. f , D C.olrfor m Plah.t ".he co et the,. .W..S nformaton and •kiA. ,rove a itel.fo a 1-..�n secfto. ieio 0 �f1GS I 2M,� SON,..��e.e��to�r�ur;,,�a�P , ..a,,..,m S,arn .I.�. ..r,., <;�_�..,,1 .�.:��. #� .�,.��� ��... �,.�.. .,.g-,�.�w, �m . �_ ._� .!�?F:►� �,�.. �: .t_,.�� �� ��.t PWS ID,#:' 4020022; pWS Name: Great Marsh Health Services Gity/Town: West Barnstable Class: COM ❑ NTNC ❑ TNC 0 .„mac , . ,.., .,.:.. . ,., > � . ,, r, rt .an ce 'I"edmefhods a $x .IDNefe ta rour�ss>Ist�atelab cefcatefor<�ro e, 11A Ge c1,.. rtn .�_ �. '� Primary Lab MA Cert# M-MA-009 Primary Lab Name: Barnstable County Health Department Lab Subcontracted? (YlN) N Analysis Lab MA Cert# Analysis Lab: 77ginal Report❑ -Re submitted Report "❑ Confirmation Report (1)Reason forResubmissiori: Resampl ❑ Reanalysis ❑ Report Correction (2)Collection Date of Original Sample TC Method E. Coli ,Method Fecal Coliform HPC Method . SM 9223 -Lab Sample Notes: DEP APPROVED SAMPLE SITE INFORMATION COLLECTION ANALYSIS " •,,,-"' @,, "r.,`'s' .;, C ' € ' a F' - fib, _ ., -,� _r �., „.., T,QTAL , ., <or C.HLO.RIN L >., „.,. .. ,. ..x<' .. :g e.... Ste' .:: :,: e........... ... <.........� ,s�, ,... ... : -':. .,.5 : F ?,. .4•. DEP,._ a „ ,.. � _._ ,., .,, _ � � -. _... . .. .. x , �z._ ., ,- ,:. _� .. � � • �� .,��r, ,.�.'SANIPLE �;� DEP ,:., RESULT .. _ . .Y.t. ' .. , .„ COLIFOR. . FE AL Sam te: _� . ,-_ .. ., _-, > -_. z �:..��, .�. •� �, � ," � .� ,4�. ._, ,_ �.; � :,rx �.�;r .. ��;<. . .,,.. : a ocaon DEp;=A roved;Sam Ie:Locatlonl x .,.. . _ ,, M RESULl', aRESULT4 ,.b,. m 2 x #.cfu/mL �� _ .. ;. . :;". aM- C . •.LECTED BYE,�. .� .T1ME, �. � �'*�. ., ,6r'"r �,.. ...°...�<�� .:`:., _ '_ � � �•.u>.< .r�: -.� u� � "�; .�:, � .,a..a _€,. 4.z RS 10000 Well#1 A 7/16/2007 10:45 7/16/2007 11:55 Derek Ritchie 741905-01 DEP Sample Type;:Location Code' #,-and DEP Approved Sample Site Location must correspond to the sample information on your DEP Total Coliform Sampling Plan. z SWTR systems:HPC.samp(es'shall be taken at the same distribution sites,and at the same time as total.col iform;.whenever chlorine resival is not detected at the sample site. 3 Sample Type:RS-RoutineDistribution Sample,RO-Original Site Repeat,UR-Upstream Repeat,DR-Downstream:Repeat,AR Additional Repeat,RW-Raw Water,PT-Plant Tap,SS-Special Sample. 4 Report as#/100 ML,P(present),A(Absent),or Too Numerous To Count TNTC-I(invalid)or TNTC-P(presehtp- ; e Collect appropriate number of repeat samples within 24 hours of laboratory notification for coliform-positive or,invalid samples. Notify DEP of any routine or repeat E.Coli or fecal positive results by the end of the business day. %certrfy tinder penalfres ofl �that kam the person authorrzed fo:fil!out this form and the rnformatron,' k •Lab'oratory authorized- s� a � '�#! t at x � sxz ... a,�" ,1 �#�;.3 '�-*'��'.rx. �� .�'2• x SG- x '. .. .. � r ycontaengd herein rs true accurate and complete,to the best of my,knowlealge, ,} .signature'and date: DEP Review Status: Accepted ❑ Disapproved Review Comments: . ' 1 �- Massachusetts Department of Environmental Protection - Drinking Water Program N Nitrate Report �fi:.;� �.���t;. ,smar ^a"aQw._•., ',�„s."�z�w`�k",7�4:,�`a.z�,�;,���, x�.�'"' `et4svz�..�w t �IN.�Y..s ;��;, a. +�'c$,b+-;;aft .��. ,s "' P't,,. � '§.t�,��'r�' ° �y, 'w �" � 's: ' 't� PWS�INFORMATION ,Please}refer�to=, our'IDEP Water<Quaht rSam Irn Schedule WQSS Ito hel c m lete tFiis form k�'-.� •. � .=:tom-: PWS ID M 4020022 City/Town: West Barnstable PWS Name: Great Marsh Health Services PWS Class: COM ❑ NTNC ❑ TNC DEP LOCATION. DEPLocaUon+Name r ,' Sample Date (LOC)ID# Acidifed?. ;'Collected Sample Information Collected By A ❑ (M)ultiple ~ '❑'Maw 10000 Well#1 ® (S)ingle ® (F)inished Yes❑ 7/16/2007 Derek Ritchie B ❑(M)ultiple ❑(R)aw Yes❑ ❑(S)ingle ❑(F)inished C ❑(M)ultiple ❑(R)aw ❑(S)ingle ❑(Finished Yes❑ D ❑(M)ultiple ❑(R)aw ❑(S)ingle ❑(F)inished Yes❑ Routine or, Original,Resubmitted or 1mesubmitted Report list below ..,_ .... Special Sarriple" Confirmation Report �(7)Reason for Resybmission (2)Collection Date of Original Sample' A ® RS ❑ SS ❑Original❑Resubmitted❑Confirmation ❑Resample❑ Reanalysis❑Report Correction B ❑ RS ❑ SS ❑Original❑Resubmitted❑Confirmation ❑Resample❑ Reanalysis❑Report Correction C ❑ RS ❑ SS ❑Original❑Resubmitted❑Confirmation ❑Resample❑Reanalysis❑Report Correction D ❑ RS ❑ SS ❑Original❑Resubmitted❑Confirmation ❑Resample❑Reanalysis❑Report Correction SAMPLE NOTES-(Such as,if a`Manifold/Multiple sample,list the sources that were on-line during sample collection). A B C D �±x't. R . .y�,9r4sr� �,�r.�, k ,.., ; T'S€��. s�.'°ssY c^Yv,:� �,. ....," n�� � Tv m '�?he'" �t� �,��; S•�"�'"��r�zy��aa € *� .c ,�,�:.�,�e , ?r' . tea,���-. ,�,� � ,; s,: cz.�,t u�� �.ac��+,� 1� la.�'. r1;�x,Y gt+ "� �,,r.r {�,g*t a'^�,:. ase.5�'u�y . ' a a� a�- r��•$.��cw. `s��z;,.'. Primary Lab MA Cert.#: M-MAoos Primary Lab Name: Barnstable County Health Lab Subcontracted?(YIN) Analysis Lab MA Cert.M Analysis Lab Name: NITRATE MCL MDL Lab Lab Method Date Analyzed Result(tng/L) (mg/L) (mg/L) Sample ID# A 0.60 10 0.10 EPA 300.0 7/16/2007 741905-01 B 70 D 10 Finished water results equal to or exceeding%of the MCL(5 mg/L)triggers quarterly monitoring. Finished water results exceeding the MCL of 10 mg/L requires confirmation sampling within 24 hours. Notify MassDEP of any MCL exceedances. LAB.SAMPLENOTES A B C Of D' 1 certdy'aunder penalties o'i taw that 1 a"thel.joersonr Primary Lab Director Signatur authorized.to fill outthis form)and the'information conta€ned herenr is.^ true accurate and:complete to=the best eh t-of my knowletl9e Date: 7 r If not submitting these results electronically, mail TWO copies of this report to your DEP Regional Office no later than 10 days after the end of the month in which you received this report or no later than 10 days after the end of the reporting period, whichever is sooner. DEP REVIEW STATUS(Initial&Date) Review ❑WQTS ❑Accepted ❑ Disapproved Comments Data Entered ... -. Massachusetts Department of Environmental Protection - Drinking Water Program Ni Nitrite Report �r� a^`�" :<,. , , :: , . - '�.k.. .r .��",�'�„�,,_; �?��= �`�I�;�'�,' t" ��� �? a`�t"'rar;��• •��'�fi e» r� M �: '"� ,�' °_ d �„� �.,. �. AIP,�WSxI;NFORMAT10Nar�Pleaserefer�toyou,rkjDEP WatergQuallty�Sampl,ing;Schedule,{WQSS).to�helpkcornplethisformx �,�•-k�„X0.;� �` PWS ID#: 1 4020022 City/Town: West Barnstable PWS Name: Great Marsh Health Services PWS Class: COM ❑ NTNC ❑ TNC DEP LOCATION Date (LOC)ID#. DEP Location Name: Sample Infotmation Collected By " Collected A 10000 Well#1 El ( El (R) 7/16/2007 Derek Ritchie ® (SS)ing)inglee ® (F)innished B ❑ (M)ultiple ❑ (R)aw ❑ (S)ingle ❑ (F)inished C ❑(M)ultiple ❑ (R)aw ❑(S)ingle ❑(F)inished D El(M)ultiple ❑ (R)aw ❑ (S)ingle ❑ (F)inished Routine or.; Original Resubmitted`Or If,Resubmitted Report list below SpeciaLSample Confirmation Report (1)'!Reason fo'r Resubmission• i. (2)Collection bafe of Original Sample'. _ .. A ® RS ❑SS ®Original❑Resubmitted❑Confirmation ❑Resample❑Reanalysis❑Report Correction B ❑ RS ❑ SS ❑Original❑Resubmitted❑Confirmation ❑Resample❑Reanalysis❑Report Correction C ❑ RS ❑SS ❑Original❑Resubmitted❑Confirmation ❑Resample❑Reanalysis❑Report Correction D ❑ RS ❑SS ❑Original❑Resubmitted❑Confirmation ❑Resample❑Reanalysis❑Report Correction SAMPLE NOTES—(Such as,if a Manifold/Multiple sample,list the sources.that were on Ime tluring sample collection). A B C D N,r":^.; r�;' '"' ra;q.,�v..+^,� "`a •,,a., °"'"#�b } �,s r.� r cx...'. ? .�'',rxor""",.g II ANALTIGALsLABORATQRY INFORMATION y § k.t..,....�. ..,,,.,,.,. ..x:.,o...x...es.µ,.�.x.,,.,, .._..,»nws. �,...,,......,. .�.,� Primary Lab MA Cert.#: M-MAoo9 Primary Lab Name: Barnstable County Health Lab Subcontracted?(YIN) L Analysis Lab MA Cert. Analysis Lab Name: NITRITE MCL. MDL ab Method Dat Analyze L e d Lab Result(mg/L). {mg/L). (m.g/L) Sample'ID A ND ].,_ 0.05 EPA 300.0 7/16/2007 741905-01 B C 1 D 'I Finished water results equal to or exceeding'/:of the MCL(0.5 mg/L)triggers quarterly monitoring. Finished water results exceeding the MCL of 1 mg/L requires confirmation sampling within 24 hours. Notify MassDEP of any MCL exceedances. LAB°SAMPL'E:'NOTES �A— B C D 1 certify;under penalties,,of law that I am the person:, Primary Lab Director Signature ? authorized to fill out:this form'and the information contained`herein is ' I of true accurate and complete toahe best ext:nt�of My-kno.w 0tlge Date:•. p If not submitting these results electronically,mail TWO copies of this report to your DEP Regional Office no later than 10 days after the end of the month in which you received this report or no later than 10 days after the end of the reporting period, whichever is sooner. DEP REVIEW STATUS (Initial&Date) Review ❑WQTS Data ❑Accepted ❑Disapproved Comments Entered CERTIFICATE OF ANALYSIS Page. 1 '�srnr,ittis� Barnstable County Health Laboratory Report Dated: 4/24/2006 Report Prepared For: John C.Doriss Order No.: G0635149 Great Marsh Chiropractic 1049 Main Street W.Barnstable, MA 02668 Laboratory ID#: 0635149-01 Description: Water-Drinking Water Sample#: Sampling Location 1049 Main St.W.Barnstable,MA Collected: 4/20/2006 Collected by: P.Major Map 178 Parcel 030 Received: 4/20/2006 Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen 1.0 mg/L 0.10 10 EPA 300.0 4/20/2006 LAB: Metals Copper 0.65 mg/L 0.10 1.3 SM 311113 4/20/2006 Iron 0.13 mg/L 0.10 0.3 SM 311113 4/20/2006 Sodium 9.2 mg/L 1.0 20 SM 3111B 4/20/2006 LAB: Microbiology Total Coliform Absent P/A 0 0 309 4/20/2006 LAB: Physical Chemistry Conductance 100 umohs/cm 2.0 EPA 120.1 4/20/2006 pH 6.0 pH-units 0 EPA 150.1 4/20/2006 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved By: ( D ector) RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 16qq lA Massachusetts Department of Environmental Protection - Drinking Water Program &AY�3��' B BACTERIOLOGICAL REPORT , - .-..a P E n J der, ij:t I—M,"Pri ppi 7Lt -1 h,'4 M Yrs s 166FE qLP.WSL PWS ID#: 14020022 1 PWS Name: I Great Marsh Health Services City/Town: JW. Barnstable class: COM ❑ NTNC U "m:II. ANALYTICAL. INRIVIAT. 1 Ni,,JR-ef rj�td,,;,yo Primary Lab MA CertA M-MA009 Primary Lab Name: 1Barnstable County Health Department Lab Subcontracted? (Y/N) Analysis Lab MA CertA d Analysis Lab Name: i Original Report Ej Resubmitted Report ❑ Confirmation Report (1)Reason for Resubmission:I E] Resample Reanalysis ❑ Report Correction (2)Collection Date of Original Sample L lif6 NbLes, 2 1 B)l -A Mdth6dri _J�fmoth6dl L �Jffil)l W0411 - I j ENZ. SUB.SM9223 MassDEP Approved Sample Site Informa tion )rChOrifiel 1 Sdwfl!AEGT r�.ilal�,4 2A IFC 'Sample Lbcatloq?, �jRegult ED 11P LJE', e L_`E_ "AT t-I Mt KDX E �i TIME" nd/L pr6V dil MID -LOrC LOCATION;, XOATT,4, 'A TTy0e ONTi R69A kedblt,, R`iesult �111, A __J RS 10000 Sink in Basement A 4/1212016 13:35 4/12/2016 16:30 D.Ritchie 1692463-01 Sample Type,Location Code and Approved Sample Location must correspond to the sample information on your MassDEP Coliform Sampling Plan. 2A SWTR systems:HPC samples shall be taken at the same distribution sites,and at the same time as total coliform,whenever chlorine residual is not detected at the sample site. 2B Fecal reporting is for unfiltered SWTR sources only 3 Sample Type:RS-Routine Distribution Sample,RO-Original Site Repeat;UR-Upstream Repeat,DR-Downstream Repeat,AR-Additional Repeat,RW-Raw Water,PT-Plant Tap,SS-Special Sample. 4 Report as#/100 mL,P(present),A(Absent),or Too Numerous To Count:TNTC-1(invalid)or TNTC-P(present). Notify MassDEP of any E.coli or enterococci positive results by the end of the business day. S Collect appropriate number of repeat samples within 24 hours of laboratory notification for total coliform-positive or invalid samples and E.coli or enterococci positive raw water samples. 1lice-rtify.,underpenatties,of,,Ia,w,that,tim the person(authorized"to„fili,,'out,thi.t'fdrmrand,,th-elfifolrmiitlon,, Laboratory authorized /��/ cofti�`&&A&j isj ih, true ffcuffifejand complete to -- 3 signature and date: DEP Review Status: 10 Accepted Disapproved I Review Comments: 'Nj S r D 4 1 iA Commonwealth of Massachusetts a Executive Office of Energy &Environmental Affairs Department of Environmental Protection SOLItheast Regional Office•20 Riverside Drive, Lakeville MA 02347 •508-946-2700 DEVAL L.PATRICK MAEVE VALLELY BARTLETT Governor Secretary DAVID W.GASH commiseionar• September 26,2014 Dr.John Doriss RE: BARNSTABLE—Publie Water Supply Great Marsh Chiropractic Great Marsh Health Service P.O.Box 122 PWS ID#:4020022 West Barnstable,MA 02668 Sanitary Survey Dear Dr.Doriss: Please find attached the following information: Sanitary Survey Report for a survey performed at.Great Match Health Service,Barnstable MA on July 10, 2014. 1 Please note that the signature on this cover letter indicates formal issuance of the attached doc 11'ent. If you have any questions regarding this document,please contact Isabel Collins at 508-946.2 2"6 or tX7 C —71 Isabel.Coll ins a,state.tua.us Sincerely, "� I Richard J.Rondeau,Chief Drinking Water Program Bureau of Resource Protection R/rc _ ecc: i e Board of Healtl Barnstable Building Inspector Barnstable Planning Board YADWP Archive\SERO\Barnstable-4020022-Sanitary Surveys-2014-09-26 PAic\ss\ss20 i 4\P:\ic\ss\ss20l4\Branstable-4020022 This Information Is available in alternate format.Call Michelle Waters-Ekanem,Diversity Director,at 617-292-5751.TDDlt 1.866-539.7622 or 1-617.574.6868 MassDEP Website:veww.mass.govldep Printed on Recycled Paper Great Marsh Health Services rramstable 4020022 July 10,2014 i Public Water System Sanitary Survey CITY: BARNSTABLE PWSID: 4020022 PWS NAME: GREAT MARSH HEALTH SERVICES i i Survey Date: July 10, 2014 Report Date: September 26, 2014 Surveyor: Isabel Collins Affiliation: DEP Person Interviewed: Dr. John Doriss Title: Certified Operator/Owner Person Interviewed: Title: Person Interviewed: Title: PUBLIC WATER SUPPLIERS: Attached is a Sanitary Survey Report for the above referenced sanitary survey site visit. i At the end of the report is a Water System Compliance Plan which consists of the following (checked items only): ❑ Table A - Summary of violations and Notice of Noncompliance(if violations were observed during the survey) ® Table B—Summary of deficiencies and required corrective actions ® Table C—Recommendations ® Water supplier response and certification, Within 30 clays of receipt of this inspection report, you must complete and submit the response form if your system has TABLE A—Violations and/or TABLE B-Deficiencies. Attach a copy of each completed. table listing the date that the corrective action was or will be taken by your system and all j other applicable documentation. (310 CMR 22.04(12)) 1 Great Marsh Health Sen1ces Barnstable 4020022 July 10,2014 SYSTEM DESCRIPTION: The health center is a transient non-community water system. It is served by a 2-inch I diameter driven well installed to a depth of approximately 70-80 feet, which is pumped via a Goulds 1 horse power centrifugal (jet) pump, located in a basement area of the building. The jet pump then feeds to two hydropneumatic "well mate' storage tanks for pressure control. There is no treatment and the system is metered. ADMINISTRATION: General System Information Is this correct? Yes ® No ❑ ;�..� . � � � {� ;' Season Poi Stets � f � r t �� >� i �`.s•6r ��.: ... Y,r::...... -._ .:........ .. . ...:..... ...A ..t ,.f „fir' p � , r PW$,'Seasgri Season Population Population hS�rvic� #Distrlputlo 'x rPWSII)� Class._ Start�, ,��n��,,S�:�ve��{Surltm+�r),_�_(Wlnker} �rt Connections = _ Systems yes; 14020022 NC 1 1011 1231 25 25 1 1 Facility Address: Is this correct? Yes ® No ❑ GREAT 1049 WEST 026680000 greatmarsh@verizon.net (508) (508) MARSH RTE 6A BARNSTABLE 362- 362- HEALTH 4533 5151 SERVICES Mailing Address: Is this correct? Yes ® No ❑ ..,r„�,"h•� - r»i GREAT MARSH HEALTH P.O. BOX 122 1049 MAIN WEST MA 026680000 SERVICES STREET BARNSTABLE Contact Information Is this correct? Yes ® No ❑ PW�iDI�}First M1 last jAddr'ess �-��� Town ''° State AZip a -�- � i4020022 JOHN C DORISS 61 POWERS DR CENTERVILLE MA 02632 5083624533 y Comments: None. Certified Operator Information: Is this correct? Yes ® No ❑ .���3.�`_ . vP11USfD#; First MI Last Addressdress_(2) Town 'State ZI ' 1No ktPhotie ..... P. x...r.......#Howl t4020022 OHN I C IDORISS161 POWERS DR CENTERVILLE MA 02632 5083624533 2 Great Marsh Health Senices Barnstable 4020022 July 10,2014 I .° ...:♦.._.,.� Crtrfied Qperator�l�rformaton ;. ... PUIlSQ# First MI Last Posltlac! License Grade ticense , primary Operator 14020022 DEREK S RITCHIE DW OPERATOR 3D/IT 7852/7395 _I OHN IC DORISS DW OPERATOR 1T OI 20779 Y .�` ; , `_ `System Dlstrlb�tlon Ciass PWSIb#s DistrbutionyClass Populatlt3rt Seruetl 14020022 JVSS __..__. ___._---.--.-------.---___--- 25 Does the PWS have a certified operator? (Verify that primary operator listed Yes ® No ❑ in WQTS is correct PWS operator) Are operator grades appropriate for system size and/or treatment type? Yes ® No ❑ Does the system have the correct staffing levels for the system size and grade? Yes ® No ❑ Is certified operator or a backup operator available for emergencies? Yes ® No ❑ Comments: None. OPERATION AND MAINTENANCE: a Is there an adequate spare parts inventory? Yes ® No ❑ Is there an 0 &M Manual? Yes ❑ No Is there a preventative maintenance program? Yes ® No ❑ Are operational records collected appropriately? Yes ® No ❑ Are records properly maintained and available for review? Yes ® No ❑ Frequency of master meter readings? Daily ❑ Monthly® Other❑ Frequency of distribution meter readings N/A How frequently are meters calibrated? Not done The Department recommends that source meters be calibrated on an annual basis. Are emergency telephone numbers posted? Yes ® No ❑ Is all critical infrastructure locked? Yes ® No ❑ Does the PWS have available an emergency response plan prepared in accordance with the provisions of 310 CMR 22.04(13)? Yes ® No ❑ Who performs emergency repairs? (Systems without dedicated staff) Contractor Comments: Contractor has spare parts. 3 Great Marsh Health Services Barnstable 4020022 July 10,2014 I TREATMENT - GENERAL: 3 Treatment listed Unapproved treatment No Treatment ® above is correct ❑ installed ❑ 6 Unapproved treatment is subject to MassDEP permit requirements If a sediment filter is being utilized how often is the filter replaced? N/A For sources without permanent disinfection: Is an emergency chemical injection port available? Yes ® No ❑ N/A❑ Are there any unprotected bypasses in the treatment process that could result in contamination of finished water? Yes ❑ No ❑ N/A Is information from the manufacturer available for reference? Yes ❑ No❑ N/A N Is chemical storage,containment, and safety equipment adequate? Yes ❑ No ❑ N/A N Is equipment properly maintained? Yes ❑ No ❑ N/A N Are alarms tested and adequate? Yes ❑ No ❑ N/A N Are chemical treatment forms submitted monthly as required? Yes ❑ No ❑ N/A N Are they completed properly? Yes ❑ No ❑ N/A N Is operator familiar with the treatment system and its operation? Yes ❑ No ❑ N/A N Is the treatment system providing 4-Log inactivation treatment? Yes ❑ No N Has the system experienced a loss of membrane integrity? Yes ❑ No ❑ N/A Comments: 4-log inactivation treatment not required at this time. SAMPLING: :Total GoIE f orm Frequency ; P,,)IUSIDiI' No pf Bacteria Samples Frequency No of 8acterla Samples x FrequQncy� (Sum N ;_ . .. ..: ... 14020022 _...._.__.. 1 QUARTER 1 QUARTER _ ........ _._ _.__ _._....... i Does the system have an approved Total Coliform Sampling Plan? Yes N No ❑ Have changes been made to the system(population,configuration, storage tanks, etc,)such that the coliform sample plan does not comply with 310 CMR 22.059 Yes ❑ No N Is the system taking the correct number of bacteria samples? Yes N No ❑ Is the system using appropriate coliform sample sites? Yes N No ❑ Is the system using appropriate source sample sites? Yes ® No ❑ Are raw water sample taps available for all sources? Yes N No ❑ Comments: Raw water can be sampled form storage tank drain. 4 I Great Marsh I lealth Services Barnstable 4020022 July 10,2014 STORAGE: Maintenance and Condition a 4020022 TANK#1 and#2 HYDROPMEUMATIC STEEUFIBERGLASS 29.5 EACH N/A IGOOD 9 MassDEP recommends storage tanks be inspected and cleaned every 5 years. Protection and Safety gg ........ 4020022 ITANK#1 and#2 N/A y N/A Y N/A Y y y The storage tanks have nearby injection ports to allow emergency disinfection. Yes No ❑ The storage tanks are adequately protected against vandalism. Yes Z No ❑ (I)Are there any holes or failures in the tank roof or structure? Yes [:] No Z (2)Have any tanks been identified as subject to flooding or run-off?, Yes F1 No Z (3)Are all the tanks protected from unauthorized entry? Yes M No F-1 (4)1S proper screening in place on all overflow pipes and vents? N/A Z Yes E] No E] Comments: The storage tanks/system could be chlorinated via modification of a pressure gauge fitting located after the jet pump. PUMPING STATIONS: s m -glb-i;gz I MT, M YROMP tl �4111122 WELL I BASEMENT 11 2N I HORIZONTAL ACTIVE 1 CENTRIFUGAL PUMP Are all pump stations recorded in WQTS? Yes M No F-1 Is there flooding or standing water in the pump house? Yes E] No [0 Does the air/water relief valve discharge have an air gap?N/A Yes ❑ No ❑ Are there any open floor drains in the facility? Yes ❑ No Are pump stations adequately maintained? Yes M No E] Comments: None, 5 Great Marsh Health Services Barnstable 4020022 July 10,2014 i DISTRIBUTION/TRANSMISSION Has the system submitted a distribution map to MassDEP Yes ❑ No Are valve locations known or identified? Yes ❑ No How many distribution systems are there? 1 Is adequate pressure being maintained?(20-60 psi) Yes ® No ❑ The distribution system has 0 dead ends which are flushed N/A List distribution system weaknesses or problems None i Date of last leak detection survey: Weekly Percent of system surveyed?: 100% Are distribution valves exercised regularly? Yes ❑ Frequency? No Is there a hydrant maintenance program? N/A® Yes ❑ No ❑ Is there an adequate flushing program? N/A N Yes ❑ No ❑ 9 The Department recommends that the distribution system be flushed hvice a year. Comments: PWS has no hydrants CROSS-CONNECTIONS /BACKFLOW PREVENTION: N rIN l PWSlptf Does,System.JaveAp:proved Gr4ss_ConneEt�on Pla>i;�Was X-ConnSurvey„Conducted'? i4020022 JY ly NTNC& TNC only: Was a cross-connection survey conducted by a Massachusetts Yes Certified Cross-connection Surveyor? No ❑ N/A ❑ Surveyor Name: Derek Ritchie i Surveyor Certification#: 31740 Date of last system-wide survey 2/10/10 Did the cross-connection survey reveal any unprotected cross- �,eS ® No ® N/A ❑ connection(s)?If yes,have all cross-connections been eliminated or properly protected? Yes ❑ No ❑ Have testable backflow prevention devices, if present, been Yes ® No ❑ N/A ❑ tested in accordance with the frequency stated in 310 CMR 22.22(14)(d)? Are there Hose Bib vacuum breakers on all threaded faucets? Yes ® No ❑ N/A ❑ Comments: None. 6 Great Marsh Health Services Barnstable 4020022 July 10,2014 i SOURCES: y Sotarce Type and Consum tton v x; �� may, ��� � %�' lvPUl'cl7 � °Jo �%�ltrC17 ' Max`I`�onthly Avg Aailys �Magic Aat�- �PWS)R #Sources � � 1fEAR �Aemand Deinan� �De _=- , 5'y Grgynd Ground. SURl��10E= Surface ' MG 14020022 1 100 0 0 02013 0.003 0.00007945 0 Groundwater Sources: Well Construction Information Is this correct? Yes ® No [:1 F, G011n»� Water Sources I :`•Source ID, SouruGe,t�ame t „�,; ,_Location, � �. ,�._Availa!?tl[ty�Ilell Type Depth ('ump 8e(ti3O�Comrr�ent !4020022-01 G IWELL 1 11049 MAIN STREET(ROUTE 6A)JACTIVE IDRIVEN 1 85 Well Inspection SSourc ID`;Yearinstal)e Gasing height(ft)lr�pjt(.Y,lN)? ell,Hause?Vents.... ed?Seasonal?Gpndltlon? !4020022-01 1 UNKNOWN IN IN JUNKNOWN IN JUNKNOWN Are all wells in use approved and recorded in WQTS? Yes ® No ❑ Are all of the wells listed on the sampling schedule? Yes ® No Are manifolded wells reflected accurately on the schedule? Yes ❑ No ❑ N/A® ' *Is the wellhead damaged in a manner that would make the source susceptible to contamination Yes ❑ No ❑ See *Are there unprotected openings in the well cap or casing? Yes ❑ No ❑ comment *Is the wellhead, cap, and/or vent subject to flooding? Yes ❑ No ❑ below Are all wells> 100 ft from the nearest surface water? (NC systems) Yes ® No ❑ Is the quantity of water supply adequate? Yes ® No ❑ I Do any sources run dry? Yes ® No ❑ If yes,during which periods and how is it handled? Comments: * Well is buried, unable to perform well inspection. Wellhead is subject to flooding, see table B-Deficiencies. 7 Great Marsh Health Services Barnstable 4020022 July 10,2014 Source Protection: I SWAP Database Information Source 1D Appro`ved Vorumeaoge( I1KPA 1 Zone Determination is Zbne 1 �olluRiprk Sources in�Qe 4020022- 1,000 100 DEAFAULT N IROADWAYS,PARKING j01 G REA Is there excessive use of fertilizers or chemicals in Zone I? Yes ❑ No Are there any known or potential, sources of pollution observed in the Zone I or IWPA (other than those listed above)? Yes ❑ No Is there an awareness of threats and an attempt to minimize them? Yes ® No ❑ Is protection area posted? Yes ❑ No Are source water protection measures adequate? Yes ® No ❑ Comments: I None. I I OTHER ISSUES OBSERVED: I None Statement of Zone I Compliance ❑Your system is currently iu compliance with Zone I requirements for the following well(s): Please he advised that any modifications to the Zone I or activities within are subject to DEP approval. ®Please note that you lack ownership or control of the required 1( 00 ft) Zone I protective radius around the following well(s): 4020022-01G If you plan to modify or expand this source or to replace any wells, you must notify DEP (in accordance with 310 CMR 22.21(3)(b), 310 CMR 22.04(1) and 22.21(10)(a)). At the time of such notification of a proposed modification or expansion, DEP may require you to comply with the Zone I requirement. ®You are hereby notified that the following well(s): 4020022-01G are in non-conformance with the MassDEP's requirement (3I0 CMR 22.21(1)(b)(5))that Zone I activities be limited to those directly related to the provision of public water or will have no significant adverse impact on water quality (as specified in Policy 94-03A). To the extent possible,efforts should be made to reduce or eliminate the impacts of non-conforming uses within the Zone I. Pursuant to 3I0 CMR 22.04(1)and 22.21(a), you must notify the DEP if you plan to modify or expand your source or to replace any wells. At the time of such notification of a proposed modification, expansion, or replacement, DEP may require you to comply with the Zone I requirement that all Zone I activities be limited to those directly related to water supply or will have no significant impact on water quality. Non-Conforming activities documented within the Zone I: ROADWAYS,PARKING AREA PRIOR OUTSTANDING ACTIONS NONE 8 Great Marsh Health Services Barnstable 4020022 July 10,2014 SUMMARY OF FINDINGS Table A—VioIations: None Please note that this document is also a Notice of Noncompliance(NON)pursuant to M.G.L, c.21A,§16 and 310 C.M.R.5.00. Within 30 days of receipt of the NON and inspection report,you must fill-in the corrected date(s)and submit this form to MassDEP and the attached SANITARY SURVEY COMPLIANCE PLAN RESPONSE FORM, including all applicable attachments. If the t➢ne required to complete the correction is greater than 3 months,submit quarterly progress reports and provide an anticipated completion date. G}VR, D fJ1te. .. T/Fm4 Cnahon . :. TABLE A CORRECTIVE ACTION . Sigiiifcant Actiou ue �Complete by.:: Date Deficient ' :P.WS I. 2. 3. Table B—Deficiencies MassDEP has made note of several items that do not reflect good water system practice and,if left unresolved,could lead to problems that are more serious.Some of these items may be potential violations,and are summarized below.Due to the item's severity or importance MassDEP has included a required course of action with a compliance date. GWR Da Action . Action Due TIF/M Citation TABLE B-CORRECTIVE ACTION Significant Complete by.'- Date: AWS 1. T 310CMR22.26 Wellhead subject to flooding. Expose wellhead and construct pit Y 11/30/2014 or extend well 18"above grade. 2. 3. Table C-Recommendations MassDEP has made note of items with a recommended course of action,summarized in Table C.It is strongly encouraged to I follow the recommended actions in order to improve ability to provide a safe supply of drinking water.Failure to do so could eventually lead to violations of the regulations. T/FIM TABLE.C-RECOMMENDATIONS 1. T It is recommended to calibrate yout,meter annually. 2. 3. *Groundwater Rule Significant Deficiencies: The EPA,as part of the Groundwater Rule,required states to identify specific Significant Deficiencies that are related to the potential for fecal contamination of the water system. Significant deficiencies, when identified at a PWS that is subject to the Groundwater Rule, are regulated under the treatment technique requirements of the GWR. A PWS has 120 days to correct any significant deficiencies after notification from the state of their existence. If the deficiencies cannot be corrected within 90 days, then the PWS must enter into a MassDEP-approved correction action plan, with intermediate timelines for compliance. Failure to have an approved corrective action plan in place within 120 days or to comply with the timelines contained within the corrective action plan, constitutes a treatment technique violation, as detailed in 310 CMR 22.26(4). If a system fails to correct any identified significant deficiencies, then the PWS will be required to provide an alternate source of water, eliminate the source of contamination,or provide treatment that reliably achieves at least 4-log inactivation of viruses. 9 Great Marsh Health Services IIarnslable 4020022 July 10,2014 SANITARY SURVEY COMPLIANCE PLAN RESPONSE FORM for TABLE A & B Within 30 clays of receipt of this inspection report,you must complete and submit this response form if your system has TABLE A—Violations and/or TABLE B-Deficiencies. Attach a copy of the completed tables listing the(late that the corrective action was or will be taken by,your system and all other applicable documentation. j (310 CMR 22.04(12)) I Please note that violations listed in TABLE A of the Compliance Plan are also a Notice of Noncompliance (NON) pursuant to M.G.L. c,21A, §16 and 310 C.M.R. 5.00 and may require the submission of quarterly ! written progress reports on the identified violations. The following corrective actions listed in the Sanitary Survey Compliance Plan(s)TABLE A and/or B has been taken by the public`eater system.(Please clieck all that apply). � ❑ My system has taken ALL of the corrective actions listed within the tinnefrannes specified in the Sanitary f Survey Compliance Plan(s). 0 For each item,I have listed the completion date of the corrective action within each table. 0 1 have attached copies of supporting documentation as required. ❑ My system has taken SOME BUT NOT ALL of the corrective actions listed within the timeframes specified in the Sanitary Survey Compliance Plan(s). My system HAS NOT complied with ALL of the requirements set forth in the Sanitary Survey Compliance Plan(s). 0 For each item;I have listed the actual or anticipated completion date of the corrective action within each table. 0 I have attached copies of supporting documentation as required. 0 1 have attached a revised corrective action schedule establishing timelines for my system to address outstanding items and I Will submit a written progress report each quarter(every 3 months)until all items have been-addressed, at which time Written documentation of completion shall be submitted to the Department. I understand that my system may be subject to further enforcement action, ❑ My system is UNABLE to comply with some or all of the corrective actions within the timeframes specified in the Sanitary Survey Compliance Plan(s). I understand that my system may be subject to further enforcement action. 0 An explanation is attached. I hereby acknowledge receipt of the inspection findings and compliance plan table(s)of the sanitary survey conducted by the Department of Environmental Protection's Drinking Water Program. I certify that under penalty of law I am the person authorized to fill out this form and the information contained herein is true, accurate and complete to the best of my knowledge and belief. Water Commissioner,Owner,Owner Representative or Other Responsible Party: Signature: Date: Print Name: Title: Return this form,a copy of each Compliance Plan Table and all attachments to: DEP-BRP Drinking Water Program,20 Riverside Drive,Lakeville,MA 02347 Attn: Isabel Collins 10 �I p -339 578 746 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Se aft umber J ice,State,&Z1P Postage Certified Fee Special Delivery Fee Restricted Delivery Fee Return Receipt Showing to Whom&Date Delivered Q Return Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees ch Postmark or Date L2 /�V7 V) F ck postage stamps to article to cover First-Class postage,certified mail fee,and arges for any selected optional services(See front). If you want this receipt postmarked,stick the gummed stub to the right of the return dress leaving the receipt attached, and present the article at a post office service mdow or hand it to your rural carrier(no extra charge). In 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the aa) return address of the article,date,detach,and retain the receipt,and mail the article. 3. If you want a return receipt,write the certified mail number and your name and address rn� on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. 4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. M 5. Enter fees for the services requested in the appropriate spaces on the front of this p receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ti 6. Save this receipt and present it if you make an inquiry. t Town of Barnstable Department of Health, Safety, and Environmental Services MA & Public Health Division . ,639� ,� FD 59 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A McKean,RS,CHO FAX: 508-790-6304 Director of Public Health September 12, 1997 John G. Doriss 34 Amy Lane Yarmouthport, MA 02675 A lead paint determination was made of the property owned by you at 1039 Main Street, W. Barnstable by Donna Miorandi. of the Barnstable Health Department on September 8, 1997. This determination revealed the presence of lead paint in violation of Massachusetts General Laws, Chapter 111, section 197. Please contact Donna Miorandi at 790-6265 between 8:00-9:30 a.m. or Tuesday 1:00- 4:30 p.m. to discuss your responsibilities in this case, and the material enclosed. Massachusetts Lead Poisoning Prevention Regulations require that you provide to this office, within 60 (sixty) days of your receipt of this letter, a written contract with a licensed deleader to abate all lead violations existing in the dwelling unit, including interior and exterior common areas. You must provide the deleading contractor with a complete inspection report from a licensed lead paint inspector. The deleading contract must be signed by the contractor and by you; it must specify that all violations on the interior of the unit and the interior common areas will be deleaded within 90 (ninety) days of your receipt of this letter, and that all exterior violations and/or window replacement will be complete within 120 (one hundred and twenty) days. This Department is required by law to file a case against you in court if it has not received a copy of the deleading contract by the sixty-first day, or if the above timelines for interior and exterior deleading compliance are not adhered to as documented by a private lead paint inspector. In a criminal case, you may be fined by the court up to $500 for each day of non-compliance. i Only contractors licensed by the Department of Labor and Industries as deleading contractors may engage in the removal, covering, or replacement of lead hazards. Neither you nor anyone in your employ nor the occupants of this unit may remove or cover any lead paint unless that person is a licensed deleading contractor. The contractor must provide written notification to the Department of Labor and Industries, all residential occupants, the Board of Health, and the state Childhood Lead Poisoning Prevention Program (CLPPP) at least five days before any deleading work begins. It is your responsibility, as the owner of the premises, to make sure that the contractor sends the completed forms to all parties. All occupants and pets must be out of the dwelling unit for the entire time that interior deleading work is in progress. They may not return until a licensed private inspector approves reoccupancy by conducting an on-site reinspection of the unit; this will be done after the final deleading clean-up. Deleaded windows and doors must have all panes of glass intact and must be weathertight. You are required to provide written notice of the presence of lead paint to all other occupants of the building. "Notice to Tenants of Lead Paint Hazards" is enclosed for that purpose. You are required to send a copy of the inspection report and the closed order to all mortgagees and lienholders of record. Questions regarding Department of Labor and Industries regulations should be addressed to the DLI office (617-727-1932). Questions regarding the Department of Public Health regulations should be addressed to the CLPPP central office (800-532-9571) or this Department (508-790-6265). homas A. McKean Director of Public Health cc: Jane Crowley Barnstable County Health Dept. e �tHE 1 � Town of Barnstable w • � Department of Health, Safety, and Environmental Services BARNSTAB1 E, • MARS. Public Health Division i63q. � AIEe " 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health September 12, 1997 John G. Doriss 34 Amy Lane Yarmouthport, MA 02675 ORDER TO CORRECT VIOLATION The property owned by you located at 1039 Main Street, W. Barnstable was inspected for lead paint on September 8, 1997, by Donna Miorandi, Health Inspector for the Town of Barnstable, who has determined certain portions of the aforementioned residential property to be in violation of the State Sanitary Code Chapter II, "Minimum Standards of Fitness for Human Habitation," 105 CMR 410.750 (J). This violation also constitutes a violation of the Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000, and Massachusetts General Laws, Chapter 111, section 197. Conditions exist in this residence which may endanger and/or materially impair the health of the occupants of these premises. DECLARATION OF EMERGENCY The Director of the Childhood Lead Poisoning Prevention Program and the Board of Health declare that the presence of the aforementioned violation presents an immediate danger of lead poisoning to one or more occupants of the premises and that this constitutes an emergency pursuant to Massachusetts General Laws (MGL), Chapter 1, Section 400.200(B). ABATEMENT OF LEAD VIOLATIONS M.G.L. Chapter 111, Sections 190-199A and the Department of Labor and Industries Deleading Regulations, 454 CMR 22.00, as well as the Regulations for Lead Poisoning Prevention and Control require that only licensed deleading contractors conduct residential lead abatement. This means that you cannot conduct lead abatement yourself or hire anyone other than a licensed deleading contractor. Violations of this requirement shall be punished by a fine of not less than five hundred nor more than 1500 dollars for each offense. ORDER You are hereby ordered to remedy all violations of M.G.L. Chapter 111, Section 197 and 105 CMR 460.000 as identified by a licensed private lead inspector. You must contract in writing with a licensed deleader and a signed and dated copy of the contract must be received by this agency within 60 (sixty) days of your receipt of this Order. Said contract, must specify that all violations on the interior of the residential premises or dwelling unit and interior common areas will be abated within 90 (ninety) days of receipt of this Order. In addition, the contract must specify that all violations on the exterior of the residential premises and exterior common areas will be abated within 120 (one hundred and twenty) days of receipt of this Order. If windows are to be replaced and you can demonstrate that an order had been placed for the windows within 60 (sixty) days of receipt of this Order, you will have 120 (one hundred and twenty) days from receipt of this Order to install the new windows. You must comply with all applicable sections of 105 CMR 460.000. Compliance will be determined by this agency's receipt of the appropriate documentation within the specified deadline, including: a copy of a signed and dated deleading contract within 60 days of receipt of this Order; a Letter of Lead Paint Reoccupancy Reinspection Certification issued by a licensed private lead inspector within 90 days of receipt of this Order; and a Letter of Lead Abatement Compliance issued by a licensed private lead inspector within 120 days of receipt of this Order. In addition, a copy of the deleading notification must be received by this agency at least five days prior to any commencement of deleading. PENALTIES Failure to comply with this order will result in criminal prosecution. The law provides penalties of up to $500 for each day of non-compliance. In addition, you may become liable for civil punitive damages equal to three times any actual damages for failure to comply with this order of a child becomes poisoned. CORRECTION OF VIOLATION BY CODE ENFORCEMENT AGENCY If the dangerous levels of lead are not abated within the time periods stipulated above, this agency may contract with a licensed deleader to correct the violation and bill the owner, or initiate court action o reimburse itself. Thomas A. McKean, Director of Public Health 9 PAR ] Real Estate System - General Property Inquiry] Help [ ] Parcel Id: 178 030- - Account No: 104853 Parent : Location: 1049 MAIN ST/RTE 6A Neighborhood: C017 Fire Dist : WB Devel Lot : 6 Lot Size : 1 . 09 Acres Current Own: DORISS, JOHN C State Class : 031 1049 MAIN STREET No. Bldgs : 1 Area: 5529 Year Added: W BARNSTABLE MA 2668 Deed Date : 060195 Reference : 9723/326 January 1st : DORISS, JOHN C Deed MMDD: 0695 Deed Ref : 9723/326 Comments : Values : Land: 64200 Buildings : 225000 Extra Features : Road System: 1049 Index: 955 (MAIN STREET/RTE 6A (W.BARN) ) Frntg: 246 Index: 1827 (WHITE CAP LANE ) Frntg: 176 Control Info: Last Auto Upd: 052596 Status : C Last TACS Update : 022696 Land Reviewed By: Date: 0000 Bldgs Reviewed By: Date : 0000 Tax Title : Account : Taken: Account Status : Hold Status : Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [178] [031] [ ] [ ] [ ] 1 .10 WY IVMWmF.%'*W Oft Ggr gal�� AzaU • Childhood LAW Governor cftLltli J/Id'l�tLllG Poisoning Prs,VWWon Pnogtsm &M P.Forsberg JOS cfoa,64, ft,-e4 Ooatons 02-00,W 800-532.OS71 seorotery Osvb K Muftan 617-&=4700, 9iW&7-4"473S CommkWorw LEAD DETERMIIJATIgNS REPORT FORM Vi?y Date of Dete at'o Inspector: License #: Method Used: m Sodiu Sulfide Expiration date: X-Ray Fluorescence Model: Serial : _ D Property Address: aAA Apt. Description of Proper y: Single family Multi-family # units Garage Fence Other structures Age of Property: Pre-1978 Post-1978 Occupant: Occu a�_t� �� un er i ears o aMOP IU Ce OB: OB: DOB: DOB: Occupant' s Telephone: n Property Owner(s) : \0 49 _0 s 3L� Afl)Y Owner's Address: Owner's Telephone: a,byte a.- An X-ray fluorescence reading greater than 1. :3 mg/cm2 or a gray or black reaction to sodium sulfide indicates an illegal level of lead .and constitutes a positive determination. Any removal, replacement, or covering of lead paint as . a result of this report or subsequent inspection must be performed only by a deleading contractor licensed by the Department of Labor and r Industries. iF _ _.. _. Pb . SOURCE LOCATION 1, Child' s bedroom Window partingbead/exterior sill area y . om Window sill bedroom 2. Child s arting � Window p area 3, Living room bead/exteri or sill Window parting area hen Kitc exerior sill 4 . bead/ t _ ....... . . . Flaking paint 5. interior_ Flaking paint 6. Exterior Cellar window units 7 . Exterior Window sills below 5 ' S. Exterior Main entry door or door 9 . Exterior casing Outside corner of baseboard 10. Interior Chair rail 11. Kitchen or Bathroom Window sill 12 . Bathroom Threshhold 9 13 . Exterior stair tread o_ Y stringer 14 , Interior hallway - (common area) � B aluste-rs I I Interiorh hallway 15. (common Door casing I 16. Interior hallway I (common area) or riser Stay" tread I 117 . I porch cap I Railing I 18. poach — Balusters 19. porch I Support columns 20. porch (<6+1 diameter or soviare) I staircase stringer I 21. porch Bulkhead I .� 22. I Exterior casing or jamb 23 . Garacte/ 1 Outbuilding Door 176 J: 24. Interior Closet door or baseboard (uncapped) 25. Interior Cabinet door, shelf, or wall 26. , LW GUILD 27. 28. 30. kS Fl f 4r 177 FORM30 HOBBS&WARREN,INC. THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF, HEALTH :77�5 / i�T CITY/TOW��N J �` W DE �I]��/�}�1� P TMENT` J/Q\/ S3 a , / I I #/V/,� ' ..- ADDRESS G^M Svey� TELE H NE Address �`�-.� -�l� WD doOccupfanIT `3�floor Apartment No. No.of Occupants �No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units � esName and address of ownef ^ , Remarks Reg. Vlo. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: 4 STRUCTURE EXT. Steps,Stairs, Porches: ( ' /') ` Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: n },i` 1 ) /"•�s Roof r Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen:Sanitation: Dampness: I Stairs: Lighting: STRUCTURE INT. •,,Hall,Stairway: Obst'n.: `.Hall, Floor,Wall,Ceiling: I/ �._ i/ _ - - • • -- � 14a I I;Li--q h t i n : , A III - C r( Hall,Windows: HEATING Chimne'"s: Central ❑Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Su I`Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vents a _ ELECTRICAL ��Panels, Meters,Cir.: ,� yH7,S M ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom f;-- Pantry ' Den Living Room Bedroom 1 M .4z�;7 /..1 — 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink _` "/ ' /��,/ ~� (' /` ; /ri / Stove 1Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Q/M Infestation Rats, Mice, Roaches or Other" ` W Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL—BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS/SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIE -OF PERJURY." o c INSPECTOR • J TITLE A.M. DATE TIME . �P 1H THE NEXT SCHEDULED � A C A.M. � P.M. � I 1 410.750: Conditions. Deemed to Endanger or Impair Health or Safety The following conditions, when .found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or-the public. Because Chapter II, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential. to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that'other violations may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it affect the -legal obligation of the person to whom the order is issued.to comply with such. order. _.... (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to •meet 'the ordinary needs of the occupant in accordance with 105 CMR 410.180 and '410.190 for a period of 24 hours or .__longer. ' (B)= Failure to provide heat as required by 105 (MR 410.201 or improper' ' .venting or.use of a-space heater or water heater as prohibited by 105 CMR - .410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. `(D). Failure to supply the electrical facilities required by 105 CMR 410.250(B), ' 410.251(A), 410.253(A),- 410.253(B) and the 'lighting in'common area required r- by 105-CMR-410.254. .-(8) Failure to provide a safe supply of water. (F) Failure. to provide a toilet and maintain a sewage system in operable ..condition as required_by 105 CMR 410.150(A)(1) and 410.300. ` (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by an object, including garbage or trash, Which prevents egress in case of an emergency 105 CMR •410.450 and .410.451. ' (11) Failure to comply with the security requirements of 105 CMR 4110.480(D). .,, ,(I) . -Failure to comply with any .provisions of 105 CMR 410.600 through 410.6.02 -.Aich. results in ,any accumulation of garbage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects ! '.or other pests or otherwise contribute to accidents or to the creation or spread of disease. - (J) The presence of lead-based paint on a dwelling or dwelling unit in ':.violation of the-Massachusetts Department of Public Health Regualtions for Lead=Poisoning Pion ve d Control 105 CMR 460.000. Prevention an .(B) '-Roof,-foundation, or. other structural-defects that may expose the :occupant or,anyone else to fire, burns, shock, accident or other dangers or f i�paff'fsent to health -or dafety. j (L) Failure to' install electrical, plumbing, heating and gas-burning -facilitias'in accordance with accepted .plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilities as are required by 105. CMR 410.351 and 410.352 so as to expose the occupant - � or. anyone else to fire, burns, shock, accident or other danger or impairment-'- 'to ..,.health or safety. - .__ Any of the following conditions which .remain uncorrected for a.period, . _of five or more. days following the notice to or knowledge of the owner I- of said condition or conditions: (i) lack of a kitchen sink of sufficient size and capacity for i � washing dishes and kitchen utensils or lack 'of a. stove and oven -"or any defect that renders either operable. (2) failure to provide-a washbasin and a shower or bathtub as required - in 105 CMR 410.150(A)(2) and 410.150(A)(3) and •any defect which renders them inoperable. - (3) any defect in the electrical, plumbing, or heating system which makes such.system.or any part thereof in violation of generally accepted plumbing heating,, gae-fitting, _or electrical wiring.standards _ that=do not create an immediate hazard. ;(4) lure to maintain a safe handrail or .protective railing for every stairway, porch balcony, roof or similar place as required by � 105 CMR 410.503(A) and 410.503(B). (5) failure to -eliminate rodents, cockroaches, insect infestations and -other pests as required by� 05 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially is $r the health or safety and well-being of an occupant upon the failure of the Owner to remedy said condition.within, the time so ordered by the board of health.. m SENDER: I also wish to receive the � ■Complete items 1 and/or 2 for additional services. `9 ■Complete items 3,4a,and 4b. following services(for an q ■Print to Yo ou.ame and address on the reverse of this form so that we can return this extra fee): card ■Attaach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address m ■Write-Return Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery y ■The Return Receipt will show to whom t!1edrtidle was delivered and the date c delivered. Consult postmaster for fee. d 3.Artcle Ad ressed to: 4a.Article Number �� 6 c 4b.Service Type «' L/ i/ �' ❑ Registered Certified Im rn T ❑ Express Mail ❑ Insured S LU m , ❑ Return Receipt for Merchandise ❑ COD 3 I C J 7.Date of Delivery ° In 5.Received By:(Print Name) 8.Addressee's Address(Only if requested 4 and fee is paid) g 6.Signature:(Addy see or A nt) T j C I v `Ei 2 i ;i ii{'t, i1 PS form 3811, December 1994 102595-97-e-0179 Domestic Return Receipt j UNITED STATES POSTAL SERVICEf �Q�' Mq p� sPaid o PM Print your name, address, and ZIP Code in this box • I Public Health Division mown of Barnstable P.O. Box 534 Hyannis, Massachusetts 02601 a.•��..���::��► •�4 Ill►«��1�1,11„ll,��<<►11►„iiI lll�,°a�,alfl!„ l�l, �fi��lsl,afl �f,�lfl,.,l P 339 578 8t00 -06 US Postal Service r ` 7 F Redeipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reyerse Se t&Number Post Office,State,&ZIP Code Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee Retum Receipt Showing to _ Whom&Date Delivered Retum Receipt Showing to Whom, Date,&Addressee's Address CpTOTAL Postage&Fees is !h Postmark or Date �7:Z �� LL a Stick postage stamps to article to cover First-Class postage,certified mall fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). m 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the d return address of the article,date,detach,and retain the receipt,and mail the article. N 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends ff space permits. Otherwise,affix to back of article. Endorse front of articles RETURN RECEIPT REQUESTED adjacent to the number. 4. If you want delivery restricted to the addressee, or to an authorized agent of the O O addressee,endorse RESTRICTED DEUVERY on the front of the article. GO 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of'Form 3841. tO' k 6. Save this receipt and present it if you make an inquiry. a i d SENDER: I also wish to receive the _,v ■Complete items 1 and/or 2 for additional services. ) ■Complete items 3,4a,and Zb. .. following services(for an , n *Print your name and address on the reverse of this form so that we can return this extra fee): card to you. zd > ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address d permit. Z ;1 ■Wdte'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N -..CC ■The Re,K�n.Receipt will show to whom the article was delivered and the date a delivered. Consult postmaster for fee. d v 3.Arti a ddres ed to: 4a.Article umber d E 4b.Service Type r° ❑ Registered Of Certified c fn ❑ Express Mail ❑ Insured w ❑ Return Receipt for Merchandise ❑ COD o 7.Date of Delivery ° 'oI p 5. eceived By:(Print Name) 8.Addressee's Address(Only if requested W and fee is paid) t— � 6.Signatut(A re gee QrAge o_ �t ;Xis k ,(A Ps o 3811, December 1994 " 102595-97-B-0179 Domestic Return Receipt Now 011TED STATES POSTAL SERVIC J R 0�� Pos a es-Paid a. 'Permit N6.G-19 221 a Print our a;10d ss, and ZIP Code in this box• Y PLblic Health Division Town of Bamstable PO Box 534 Hyannis,Massachusetts 02601 Fax(508)775-3344 Phone(508) 790-6265 The Town of Barnstable Health Department 367 Main Street; Hyannis, MA 02601 rNa ay M Office 508-790-6265 � � `S 5,rA aA rsldyonornu A. McKean FAX 50b.j7pe344 311 o4m Y�!/` -V Director of Public Health '� '4 .Jog� ��"` y40a [ rd � NOTICE TO ABATE VIOLATIONS OF_105 CHR 410.00, STATE SANITARY CODE II MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION The property owned by you located at/,O�q ` ��� ` as inspected on 0'-6-Z..y , Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CHR 410.00, State Sanitary Code II, Minimum Standards of Fitness for Human Habitation were observed: You are directed to correct these violations Xthin twenty- four (24) hours of receipt of this notice. You are also directed to correct within days/hours of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean Director of Public Health . L . f - � •. .ion ♦. •.,+ , ». `S � 1 EVE Town of Barnstable Department of Health, Safety, and Environmental Services r B,, MAM. ' Public Health Division y A98. plF p�a 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A McKean,RS,CHO FAX: 508-790-6304 Director of Public Health July 23, 1997 John Doriss 34 Amy Lane Yarmouthport, MA 02675 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE II MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE, ARTICLE 51 The property owned by you located at 1039 Rt. 6A, W. Barnstable, was inspected on July 22, 1997 by Edward Barry, Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code H, Minimum Standards of Fitness for Human Habitation were observed: 410.500: Broken glass panes at hall window. The floor of the back bathroom was not secure to the floor joists. 410.190: The temperature of the hot water was only 90 degrees farhenheit. 410.351. The heatingunit in the dishwasher was malfunctioning. 410.481: There was no 20 square inch sign posted which provided the owner's name, address and telephone number. You are directed to correct the above listed violations within seven (7) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. PER ORDKR O HE B ARD OF HEALTH T o . McKean Director of Public Health cc: Stacey Gendron FORM30 HOBBS&WARREN,INC. _ THE COMMONWEALTH OF MASSACHUSETTS • BOARD OF HEALTH W F/ /y--s`r 9 yrrowri DE °�M SV•y,W � 7 pb�SS�- Address > �ccupan floor m. o: R P .ryo_Occ i5ants— J7' s '•�� No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming unit � No.Stories Name and address of owner / !/ 7a�ks Reg Vio 7rs YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: mm STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: /.I ,vl, fy�LJ �• 0 7• !s` `� S •e Hall, Floor,Wall,Ceff(croerd Hall Lighting: 7YQ Hall Windows: ' �} „¢ -61 oG HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair + TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: ,,,e,ni tl 4 �j H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 —Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Livina Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove �,. <c v �. In Al Cs �-r�Al�l t1�<�" Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Ho taq"</z,/ f11,;X11 7— Wash Basin,Shower or Tub: l Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: A* ,,va ,�`� �d�lV� ���5�;, .5 l►11 t��'i� ONE OR MORE TFH'E"VIDU*-T(Of S"CHE,�leEEb�ABOVE�IS�e0K0ITY1 W1VHICH 7 e� � "0 $/ MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL—BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." - INSPECTOR r /1 TITLE � / �► _ - � ,A Mrs DATE, ` - TIME , , P.M. THE NEXT SCHEDULED REINSPECTION P.M. x 410.750:. Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the. health or safety, and well-being of the ,.occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as,a determination that other violations may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or 'correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it affect the legal obligation'of the person to whom the order is issued-to comply with such order. i (A)-`' Failure to provide a supply of water sufficient in quantity, pressure - -and-temperature, both hot and cold-, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 fora period of 24 hours or - longer. _ (B)- �Failure .to .provide heat as required by 105 01R 410.201 or improper _ _venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. -4 -(C)-Shut-off and/or failure to restore electricity or gas. - r (D). -Failure to supply the electrical facilities required by 105 CMR 410.250(B), - - 41MM(A); 410.253(A)•, 410.253(B) and the 'lighting in common area required _ by-105 CMR 410.254. (E) .Failure to provide a safe supply of water. F - 1 '(F) Failure to provide a toilet and maintain a sewage system in operable - coAdition as required by 105 CMR 410.150(A)(1) and 410.300. - `'(G) - Failure-to provide adequate exits, or the obstruction of any exit, - . passageway or common area caused by an object, including garbage or trash, which prevents egress incase of an-emergency 105 CMR 410.450 and 410.451. _ Failure to comply with the security requirements of 105 CMR 4110.480(D).' (I). Failure to comply with any provisions of .105 CMR 410.600 .through 410.602 r 'which results in any accumulation of garbage, rubbish, filth or other causes 'of sickness which may provide a food source or harborage for rodents, insects �Mr-other pests or otherwise contribute to accidents or to the creation or _ ;.spread of disease. -(J) - The-presence of lead-based paint on a dwelling,or dwelling unit in :.violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and 'Control 105 CMR 460.000. _ (H) 'Roof "foundation, or_o_ther structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or _ -"Oftfient to' health -or dafety. - - - VOLY Failure to install electrical, plumbing,'heating and gas-burning facilities in accordance-with accepted plumbing, heating, gas-fitting and •electrical wiring standards or failure to maintain such facilities as --`are required by 105 CMR 410.351 and 410.352 so as to expose the occupant or anyone else .to.fire, burns, shock, accident or other danger-or impairment to.,-health or safety. _ .(!t) Any of, the following-conditions which remain uncorrected for a period of five or more da_ys_following--the notice to or knowledge-of the owner Hof said condition or conditions: O.. lack of a kitchen sink of sufficient size and capacity, for - washing dishes and kitchen utensils or lack of a, stove and oven or any defect thit-renders either operable. (2) - failure to provide a washbasin and a shower or bathtub as required ' _ .� in 105 CMR 410.150(A)(2) and 410.150(A)(3) and -any defect which renders_them.'inoperable. - _(3) any defect in the electrical, plumbing, or heating system which makes - such.system or any part thereof in violation of generally accepted ,plumbing heating,, gas-fitting, or electrical wiring standards that do not create an immediate hazard. (4) failure to maintain a-safe handrail or .protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.55;. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially Impair the health or safety and well-being of an occupant upon the failure of; the owner to remedy said condition within. the time.so ordered-by the board of health..