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HomeMy WebLinkAbout2003 05-12 ' l :� � Massachusetts De artment of Environmentat Protection � � � �- �/� � P � w Bureau of Resource Protection -Titie � . DEP Approved tnspection and �&M Form for Title 5 VA Treatment and Disposal Systerns ' A. fnstattatian - ������ j2!�(� /�'la�������, When filfing auf �er farms on the {�„ � ��/v�i�� computer,use l�' / only the ta6 key FaGtity treef A ress ��� to move your �, a v- �yj � �6'�'�V� cursor-do not e� Zip use the retum key. MaiEing address af owner, i#dififEren� $�► Street AddresslPO Box � c� State ZP j � ) - L')Ct. Telephone Number j G I i 8. Authar[zed Service Provfder ; � P �'tv/! i/rrd�r�? � �P2VE C'-pS �� C ; � O&M Firm �� n��j�,� ��r i l� �Street ,2GJr�G( ���� /� / `r �-��� State Z�P City ( �/D[ } ?��- Qj,3d ext. Telepho�mber �- ���-��+s s�,S"? Cert�ed Operator Name Certifiica#ion Number C. Facility/Sys�em [nformatian � di�t1��' r3 /to � : DEP!D Ma�ufac#urer 1D Mode�Number insta!lation Date Stast of Operation Appraval Typ�: �Genera( ❑ �rovisional[�Piiating a Remediai Seasonat Residence—used tess than 6 mo./year. (]Yes�No D. Operating information .Sr-/� '�� � '�`"f�� � Inspeetion Date Previous is�speetion Bate ', Pumping Rer..ammended Yes❑ No ' Siudge Depth(to be chedced yearly} _---- - - � Effluent Descripfion ` T5tAOM1 •3i28to2 � Page t of2 t ,. �. � � �_� � t l�assachu�eti� �ep�rtment of Envirca�rrs�ntat Prc�tectio�€ � . f �E.IC2e'�l! C���{�1i.lft� �1't3�S'G"�I{?£'{-�tt�@� � t ��� ����r��ec� ����e�tinr� ��� ���f �c��� fc�� 7'i�d� 5 ��� , . `r€°�����t a�td ��s�o��� ��st��rs �. Sa�r��li�g tr�farma#�c�n samples'Taken: j�in�uent(�E�fEuent Pa�-dsrte�sar�pie�f:Q PH{�Ba0 Q T�S f,"i T��,�, �.�et�(t�st be{ow} - tTmer t �Q*� tlthet 3 ����+P�c��of ary ma�nt�ar�e per#�srrned sinr.�prevlous irrs�ec�ion&d�tcitsg t�is inspec#icn: � � t�otas a�d Cairttrtett�: : G�-E' � ,_—_ _ ��-0� S�,S/`, � � �`�— I � F, Ce�ificatic�� t c�r�#`y: I h�ue inspected���e tre�ne�rt and dis�SaT sysi�m at ttte adcfc ess abave,have � l��P�d this repoc€an���aifacF�ed techrrolQgy o�eraEi�€t and maintenaric��heciciist,and t#te Ott tepatt.�d' t�,te,��,trate�and r.ampfiefe as af the#ircte af the inspe�on. f am a C lc'3�Qt'ti7 e3C I � �rcanca wit�2�7 � Ctv�R 2_t3t1. tar �gnatare — S�-7 —t�3 '', �:�e � SYstem nwnet must�bmit ' • • II t��he Ic�J tf�rs repart, �c.�nofagy OS�M cnecicSi�a, n„d any FSC�i�3IT�'Cil S'c�RTCittCJ'�=sutrs �Ch�T'd Gf�P.�3��I�Cj��p 8ff Tp!(4VY5�QC�C�'E!flS�BG�lOfi�I�OfiTt�: 31���e—by Jar�t�ar�y F'itating SF P�roviseottat U��- Get�erat Lise—by SeFttetnber �'�ar the with�n 3�days af inspectior� 3Q�'t�f eacts yeac#or#he previtu�s Catentiat'year c�ate pr�evious?Z months Dep�rtment trf Et�vir�s�tet�af Protet� Af#er�iort: T�5 P�ogram �e 1Ninter S�reet,6`"�Iotir �s�o». lUlA fl29�J8 T�IA{3�l1 •3r�exy2 as�s�of z � I �}--2i—c�32 �=1'?E�'I FREC`f 3L� fi�T IE�6 i tl 1010821 i`7�`79�3`� P.t31 � � ��/U///� /� -��i92� �tNG�ILA,�R$ERTVI����K L�'!" Srz f"itter ug€ight in tuh,run (va'itLt 5�ite�Ite�'� /,, ,,� s3caa Brat�it�o it untit the � �SSI i�1f).-��'�W 2'��v/� water fl+�+s auc of dte hoEe en c �A.1`E€�F�E1�13IC'�:��.L Ltr�'T ������ ; SE3�.�#C�T�'ERFiC�� �� _ , (�t�) �p�g unth ritaa • , urazer siovvly flawing und3 the a�t °RV�tn be�'c� �' exit�g waxer ss c�ar- • i �c ����� F'misk�s�u8da�wnf�iaac ( chamt�r for aurmsE�:a�� �haggec ' C�ck�s���' �v te�sca�ts,a�#k�s ���� '1 $ecand Rs�P�xC COVCs' Pfes�t fsker iFt piaEe.fi'tI ruitit i �� - s�s.�r sads�inlc it �# Cn� �3g�a�sett+�"C3(�"' - 'tta�s ca� ' #�,TePiacc '� tlen�' l�it�u ' }�tar i � Seran� �kr�i��€J��' t�na�tecovtr ' . � �e�,,ing ae�pr a�tifc aut � ����co� ��wara�+�Fsber pads �ist� . �farmart��-� � , C�k s�t�riser fx�Asaf�. C��`ire so it es etvt in casuact , tape Ifueedr.d '�"�'��g . 1T'ash afF�`p�ic�+cdc i�ocr�mcxr : �U�9�•fttliT.CZ3C�C �� �C SWWC���II�a��4~ .fi . t�t�¢'�R RCt#1tOt�. �� �Qk t �S"`'���' C1asa aa,d IocTc cot'�x � , -�'� g,�O'v��sacte�c ccsver and Read a�d re�d���' � a�asnber re�mvcfi.Iaertap• •� ' T�t i�t���g � Lea�u�e of seruice with ! ' �C �t�a � ���� � - 34c�m m�tpa�y�'ite a�' E Cz+ons fi�rto5est bcr. i�Y��lem i Li€t f�r with as j �� Iruiicate if any fot[ow.s�i� � F�ot�t put it�a tab °� � outsictc c�fii�e w� �e sure Po c.omp3�fie tsn c}csis b�na� se�vic��ittc�ot�e � M�M� �,/ Q �'�Iny ' ���!'�� ��������/J�� - - _ - _ r ;,, �����G ����� ��� _ , ., s�-�� . SPS� �7`v -ro�ra� �.��