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2004 07-16
t a � - ;. i y f� i _ - LMassachusetts Departme�t of Environmentat Protection Bureau of R�source Pra#ection-Titie 5 . �'�� [aEP Approveci Ir�spection and ��A�! Form for Titie 5 !/� Treafine�# and DEsposat Sys�ems ' � � 2 � � I A. �ns ita#ion /� � . ; , �,��.� �[ C l� /I���G 7crrct j what,etf�q«rc i fortns on ths { �COR1ptl�tt.� F _ . ��� � �� - «��«-�� � uso t��stum . _ T-'P key. M�itftg 3d O#OVYRer, if dif[etEnt � s�� � � � � � � � �. Tetephone Nuenbar B. Authari�ed Service Pr�v�der J�IP9�v�tt� �!�{�»r�o'!l1�P�1�� �P1ret11C�S , .LnG . �� � 9 �q��•�l,'d� - �tv�. � ra vl a�f�c-� �� oa�'os c�o�i?�S_ 4�3oe,�. � � �� �'���,�f�r��s S�s7' c�ea c�ae�acorrvamo c����,►�� C.-Facij�tir/Sv�m intormation �'�_/���'7� - /f/a,e�ec o 4(�a ��o : ��a �� �i� �03 y,�io�3 _ Ins�on DeEe —'�'�—' start af Opetade+t Approvai Type: [�Genera!Q Provisional�Pitoting 0 Rernedia! ' / ` S�asonal Residance-used less fhan 6 mo.tyear:QYes�No - ' D. C� rati g tnformation � � ��v �as on s P:mous 1. � .oa�e -� ', Pum ia Recommended ❑Yes. Na studqe be yeartyj � � _ no�c`�r��. a t 2 ad��J�P-�.fi . ' �Afuent Descr�ptiort TSiAQM1-sr2er02 Pa�' I Massach� E�partrt�snt of Environt��tat Pro�ectiQn j Bur+eaet af Resouice Prc�t-Tdie 5 _ DEPR Approved ls�spect�on and flB�M Form for T'ttle 5 UA Tc�eatment��d Dis�osai Sys#ems � � � E. Sampting Intormation sampl�Tatc�:p�nfl�aent Q Ef�uent Paracrtetets sampie�:Q pH�BOD[I TSS Q TN[�Othet(�isi bebw) r Otl+os t Othet 2 Otlier 3 � D �a, any rrnaG,cenar�ce p�farrned s-�pnevio i�s _ ' &ri ' this kisp�ion• � a c L. ��� _ C : Notas�d ca�t� ���� � � �j� . � � � � � �"_,���i2�/,��2U���:�C.�� F. Cee�tif�catio � n. o vs.�_ _ i c�rMy:i trave�the seyrage�aunent aad disposa!system at the�ess aDo�e.have campieted this re R and the att�hed te�nobgy operabon and maintenanoe checkGsk and the . is tru r3te,and�as cf the tirne of in8pecifoe►. i am a fis a i��dance 257 CMR� // Q.y , w � ' 5ystem ownet must submit this repo�t.tec�nology OS�M cneddist,�i ,anY re9nir�d samc�ing�sutrs ta the loca!board of heaitl�t�nd DEP as ioqaws for each inspection pe►iom�ed: Re�t Usv—by.lanuary Pito�ng b i'�ovls�nai Use- Gs�ral i3se—�y 5ept�mber 31'`af eac�_�rear fi�the w�n 3�days of ir�s�Ctian 30°i of each y�a�for the prewfoiu calendat'yeat da�e previous 12 r:wnths Departtne�t of EnvittinmerrtaE Protec:ion �e�,: r�s�� ane wmter sr�eet,s"'Ftoor 8�ton. MA a'I108 TSfAOM1 •3128A2 Pa�2 d2 t � I - � __ . _ : � 1 � ; . � . � �P /�� � 1����,�� . t � � j SIl+IGULAIR SERVICE 4'R£CK LI�S'i' I (.�.gh s�e�1 sa fil�er nqaigbc a�mh.rao �M ^ elean waoec iaoa it u�I d�e � v�Nv�_ � MI�Q fIOM�S OO[OE{5G IlO�G iO ; �a�oF�,��� _� y ��.�� . s�tvcca��tFo sY: __ ����,�n►� �m,�.�►�� . ; i - ,raeer sioaet�,�,u.,;,,g aen7,be � � I ars�tfo�n �Iiork to be ovtocaed D�oe a[Hios wraimr is ciear: � : F3rat Re�ave wocteie cotier,cl�xl� �1�osio�dv.,a�ev � ci�amber farmnaaEw�a�rlcd .i �� - C�slud�e depth at�er seeand�rcx af opermoa Appigh�hriamitm Sioer#iange � Seoo�d Rtmore ao�cese cover i � � , �'ltce liller in place.�l+ridt i � tlwn v�oet�od sml�a : - Cosh+ot Open and setoo"C�O�r' _ � a�u1Q positian � , Tmo a�a bei�'mg c,6s,�ryi� 'j . �Oet 40�t� ' $a+oad L3ce![ai[$ow netaKCr ' ebaniber ,.� ,� R�pLoecaaa�7ecaver � F Uo�ng arraioor md tih wc Fasc Re�iaoe waaae ow� . _ c�mier . tyeck!6r rroas�ber pads _ . � Secood Pf�g a aaao�r Cbeclt fa�ea ar�ob�a� �� . �lcelc�rine'snw fa;�Og. _ G�:rae so a is sa m cvnaa tape�neaded �aau�tiog . WasL o�aQamof p��b�ck . Repiar��oaeee oo�e= � Eiooi�uP�.cbeck Caal.bi Att swi�4 cQ AITYO" �.���. 3. 8' � � r � cw�,�a�� ' rm�a x����o��,a .f s�aobcc ea�e fi�r aop. Brad�d ieoocd boar mear :' Tcra ia M�clt Ioci�ag eaba Faper l.s�ave ao6ct af setvict wa6 � •�vrk vwaer � , �ntl paa�Q aqd s�ct p�apia� i 6iom fi�!0 5tst d�ba: ' Plo�e m oo�opa%p�aa� ' Lift fil�e,c wun rope�s aegWaric�r p� ' er � 7ad�me�aoy�Olbw-�p is j L�t ont�pat ic m wb necemicy i . i Ckan ehe ourside af Si�a wid� Be sme�o cae�eoy6fe m � waee�dcain bar�c�D.fiest sarnio�,cet�a rt�D o�ct i � J J C,�, i �i� MEMO: U � � �jCJ� /� � ��«���� p � Zv�Z�� � ��� � C�/1� � . j � �:����� a ; ; ; 0 �