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Home My WebLink About2015 Jan 06 - Bioclere Field Reports from Coastal Engineering COASTAL ENGINEBRiNG TRAN S M ITTAL COMPANY, INC. 260 Crenberry Highway,Odeans,MA 02653 508255.6513 � Fax 508.255.6700 � coastalen9ineeringcompany.com To: Department of Environmental Protection Date: 1/6/15 Project No. WYA024.00 Attn: Title 5 Program Via: �1st Class Mail ❑Pick up ❑Delivery OFed Ex One Winter Street, 6`" Floor Fax: Boston, MA 02108 Phone: ��Q��D �AN c a 20�5 Subject: Shaw's Supermarkets, Inc. No. of pages to follow: HEqLTH DEPT. 1106 Route 28 South Yarmouth, MA PILOTING USE PERMIT ❑ Plans ❑ Copy of Letter ❑ Specifications � Other see below We are sending the following items: Co ies Date No. Description 1 12/14 WYA024.00 Monthl Operations Check Sheets 1 12/1/14-12/31/14 WYA024.00 Bioclere Field Re orts 1 12/9/14 WYA024.00 Dischar e Monitorin Re ort Form and Laborato Report �for approval �for your use ❑as requested ❑for review&comment ❑ Remarks: Enclosed are the reports for O&M services conducted in December 2014.The system was operating properly during the reporting period.The effluent test results show good system performance, as all discharge limits were met. cc: Y �� ' �'� � By: Chad A. Simmons George�iannou'YoU is, aw's AquaPoint.3 LLC CAS/VSW D:IDOCIWIWya10241Reportsl 2015-01-06 TransDEP.doc NOTE: IF ENCLOSURES ARE NOT AS NOTED, PLEASE CONTACT US AT (50H� 255-6511. Yarmouth Shaw's Supermarket WYA024.00 Month: pect,-, ,r Year. 2014 lnfluent Effluent ammonia alkali�ity Nitrate Nitrite Ammonia alkalinity Flow(x100) Generator Date Time Operator pH mg/l mg/I -CaCO pH mg/L mglL mg/L mgll -CaCO Pump#1 Pump#2 Hrs. � n z 7.s �y �. �k�o -- r �� 3�_� 3 G'2( S(o,.( 4 5 6 ,� — 8 ----- 9 lo fl�wt 7; O„�'_ �1J /- �� "- / ��"� `J36_7 -10 s":z� ,�i,,,� 11 12 --- - — - 13 -- - - — -- 14 15 16 17 --- — _ 18 — — �s - f sk , o:;�._-___.. ! c� _ __ l`i9 rZ� Z_ �, 20 ----- :2�.z��_ 21 - --- 2z - --- -- 23 ;a=r s�-. _y .S '/ � � � - `2G `�37-� k 2a �2 s� � 25 -- 26 27 28 29 30 31 r z 2v t� To�,� Fle�v - ,�h , 2�to y�,ue� D:DOC1lMWYA10241Field Test Form.xls Z (� � `� G'e➢ Yarmoufh Shaw's&upermarket WYR624.�4 Month: �r«m�'1�•^ Ysar. 2014 EfftuerttPumps Pre-Aeration �QSystem Anoxic Hours Counts Haurs Alarm , Mid-Levei Amps Alarm Amps Alarm Bats Tirne Qptr pump#1 pump#2 pump#1 p�mp#2 onloff caunts p#1Ip#2 on/aff p#1fp#2 anloff 1 2 ?P t� :��z��5 �tt,.� o"t lS�S SYw2,9 t�FF f�&' �f� a�/ �_S' �i�3 v�'� s a � fi 7 8 s v.4 �kM �a�.G �.�a.+�t )ft2 t�r �55�2.3 o,r'� .�, .5.� Grv y.y 9�:? esrt' To 11 12 13 14 15 �s � � 17 18 99 "�=A st� �"�,3:6 �.1z_ t f't`7 tt'23 3SGi3,� e:r� S.7 .s''t d ,7 5- c+�� 4�r�s��r 2D `/� Yz '�'I 4 n 1 t, 6�3 '., / �+ y��,, 21 � � � rt i15'ih �°"� `�,�✓�-1. 22 ✓- 3 S� f� � 23 —P s(� ?23.&6 �I2_$S' 519 lr�S f7a.gy, o��= �:`d 5.b onl `�=`I 4•$� c7�'!" 24 25 26 z� za zs aa 31 �,'�E D4 � , t2 l �� `l � Massachusetts Department of Environmental Protection �:` Bureau of Resoure Protection - Title 5 ; �` DEP Approved Inspection and O&M Form for Title 5 t/A Treatment and Disposal Systems Important:When . . . . . fillingoutformson Q. �IlSt8��8t1011 the computer,use - � � . � . onlythetabkeyto Shaws.Supermarkets, Ina � � � move your cursor Owner � . -do not use the ��06 Route 28 retum key. � Facility Street Address Yarmouth 02664 � ciry Z�P � Mailing address of owner, if different �^ P.O. Box 600 Street Address/P0 Box: � � East Bridgewater 02379 City State Z�p Telephone Number B. Authorized Service Provider Coastal Engineering, Co. Inc. O&M Frm � � � � 260 Cranberry Highway . Street Address . . . . . � � Orleans MA 02653 � pity � State � Zp . 508-255-6511 Telephone Number Sean McCahilf 12449-R Certified Operator Name Certification Number C. Facility/System Information W033722 30 Series � � � � . DEP ID ' - ManWacturer ID Model Number � . 2005-06-03 2005-06-03 Installation Date Start of Operation Approval Type: ❑ General ❑ Provisional � Piloting ❑ Remedial Seasonal Residence- used less that 6mo./year: ❑ Yes � No D. Operating Information 2014-12-09 � � Inspection Date . � . , � Previous Inspection Date . Pumping Recommended ❑ Yes � No � . . . Sludge Depth � � . � � Massachusetts Department of Environmental Protection �� Bureau of Resoure Protection - Title 5 j j� DEP Approved Inspection and O&M Form for Title 5 VA Treatment and Disposal Systems E. Field Testing Field Inspection: Color. ❑ Gray ❑ Brown g] Clear ❑ Turbid ❑ Other(specify) Odor: � Musty ❑ Earthy ❑ Moldy ❑ Offensive ❑ Turbid Effluent Solids: � No ❑ Some pH 7.1 SU DO 0 mg/L Turbidity 0 NTU 6 to 9 2 or greater 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: 0.00 gpd Parameters sampled:❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑ TN ❑ Other(list below) Other 1 Other 2 Other 3 G. lnspection and Maintenance Description of any maintenance performed since previous inspection &during this inspection: Conducted O&M. Checked pumps and controls. Cleaned the spray nozzles and fan boxes. Field tested the effluent.Checked the EQ and anoxic units. Mixed up sodium bicarbonate solution for process control dosing. Recorded the system settings and readings. The system is operating properly. Notes and Comments: Conducted O&M. Checked pumps and controls. Cleaned the spray nozzles and fan boxes. Field tested the effluent.Checked the EQ and anoxic units. Mixed up sodium bicarbonate solution for process control dosing. Recorded the system settings and readings. The system is operating properly. � Massachusetts Department of Environmental Protection ��' Bureau of Resoure Protection - Title 5 £ i DEP Approved Inspection and O&M Form for Title 5 1/A Treatment and Disposal Systems H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted the required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I am a Massac usetts certified operato ii�ance with 257 CMR 2.00. � �� 21�/�y Operator Signature � Date System owner must submit this report,technology O&M checklist, and any required sampling results to the local board of health as follows for each inspection performed: Remedial Use-by January 3151 of each year for the previous calendar year Piloting Use-within 45 days of inspection date Provisional Use-by March 31�'of each year for the previous 12 months General Use-by September 3151 of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street 5th Floor Boston, MA 02108 -- lS rS , COASTAL ENGINEERING CO., INC. 260 CRANBERRY HIGHWAY • ORLEANS, MA 02653 TEL. 508 255-6511 FAX. 508 255-6700 BIOCLERE fIELD REPORT - - - Pro'ect No.: ' - Dafe: � Time: � instauation: Tested: ' _ Client: Service: Commissioned: Address: �.L � : ,� ` Othec Scheduled O&M:,� Ins ector: ; . �E b.:� _ _ Bioclere Model Number s • 1 Odor around site? Y/ Source of odor? Check all that appl : - Miid: n�tedium: Strong: Musty: Se Fic: 2 Take influenUeffluent sam les as re uired. � �� c� �35�� ',� - .l�v iis ' e� tZ� , Nf� . )_ " ' o„ U:S;' Al� 3 a M asure slud e in rima tan and rease tra s as re `uired: b Slud e de th in rima tank' �I� ;� Scum depth: _ Siudye depth:-;, c Does tease tra need um in ? + v i N UNIT 1 - . UNIT 2 BIOCLERE VENTS a Is air assin throu h the vent? V i N Y N If in doubt ut a small lastic ba around vent and allow to fill. b Is the fan o eratin and in ood condition? N N GENERAL a An external dama e to the unit s ? if Yes, rovide details on back. v i Y b AFe cover, fan box and control anei securel locked? N N c An filter flies in the unit? Y/ few/many Y w/many Location of fiies d Locks/latches/handles. OK? / N 1 N e Lid asket OK? i N /.N Does the fan box contain standin water? Y � v If Yes, then remove water and clean drain holes if necessa . BIOMASS CHARACTERIZATION a Color of biomass? 1)white 2)white/gray 3)gray 4)gray/brown 5)brown 6)red/brown 7)black 8 other _ . 6' b Thickness of biomass 6-12 inches below media surface. 1 li hf 2 medium 3 hea � _ _ NOZZLE SPRAY PATTERN a Does s ra cover the entire surface area of inedia? Y i N Y / N ff not, clean each nozzle with a bottle brush Does the s ra now cover the entire surface area? Y / N Y / N If not then: 1 remove nozzles and soak in a bleach solution 2 manuall en a e both dosin um s for two minutes 3 re lace noules Does the s ra now cover the entire surface area? Y i N Y / N if not, consuit AWT Environmental, Inc. PUMPS AND CONTROL PRNEL a Record dosin and rec cie um timer settin s from controi aneL Dosin Pum 1: min on: (4 min off: L min on:(a min off:2, DOSIfI Puf71 2: � � � - � � . . min on: f� min off: min orr. �,� min off: R2C CI@ PutTt : min on: 3 hrs off: ( min on: hrs off: . r � � . . . . . . . . '' In Bioclere control anel set dosin and rec cle timers to a test c cie: a Am era e of dosin um 1: 5•�j amps amps � b Am era eofdosin tJtTl 2: f, amps amps � c Am era e of rec cle um : amps /�_ amps - Are dosin um s alternatin ? c� � N �i N 3 Are the timers o eratin ro erl ? �/� N �'/ N �sualf ins ect rela s for wear and record roblems below. ' if s are com onents are needed contact AWT If an ammeter is not available,set the timers to a test cycle as above and at the Biociere check the um s's o eration as follows: Dosin um s: check that um s are o eratin , alternatin and the Pump 1 OK? Y ! N Pump 1 OK? Y / N desi nated rest c cle is occurrin . Pump 2 OK? Y / N Pump z oK? Y / N OK? Y / N OK? Y / N 'If pumps or control components are nof operating properly, record below And consult AWT Environmentai, inc. RESET TIMERS TO ABOVE SETTINGS: Note an chan es hefe: min on: min off: min on: min oif: *Do not chan e time�s without consultin AWT Environmental, Inc. min on: min off: min on: min off: PLUMBING a Are the unions in the Biocfere leakin ? Y / v i If es, then ti hten with i e wrench FINAL CHECK a Main ower"on" and set to le for all um s to "normal" osition. � N N b Ala�m fo Ie sef to the "ON" osition. Y � Y i c Lock control anel, Biodere cover and fan box. ,/ d if ossible, record the water meter readin : REPORT SUMMARY: r �OY � C Jv� N ! GM r.�l"t'�" il�C� d[ r r- � d nw a a tiI� n Yv f � ` � ` `Y � D O - I� �Y . tC r i t f � . . . . . . . .. . .. SIGNATURE: D:IFORMS Curren�ITechServue -W stewaterlBioclere Field Report.doc , �a �a31 ►`( . Massachusetts Department of Environmental Protection ' �;<"- Bureau of Resoure Protection - Title 5 � ��" DEP Approved Inspection and O&M Form for Title 5 !/A Treatment and Disposal Systems Important.�When � . . . fiuingoutformson A. Installation the computer,use onlythetabkeyto ShawsSupermarkets, lna � . move your cursor Owner -do not use the ��06 Route 28 return key. � Facility Street Address Yarmouth 02664 � City Zip � Mailing address of owner, if different: 'e°�" P.O. Box 600 Street Address/PO Box: East Bridgewater 02379 City State Tip � Telaphone Number B. Authorized Service Provider Coastal Engineering, Co. Inc. O&M Firm 260 Cranberry Highway Street Address Orleans MA 02653 Ciry State � � Zip 508-255-6511 Telephone Number Sean McCahill 12499-R Certified Operator Name Cert�cation Number � C. Facility/System Information W033722 30 Series DEP ID - Manufacturer ID � � - -Mode4 Number 2005-06-03 2005-06-03 Installation Date Start of Operation Approval Type: ❑ General ❑ Provisional � Piloting ❑ Remedial Seasonal Residence- used less that 6mo./year: ❑ Yes � No D. Operating information 2014-12-23 1 Inspection Date Previous Inspection Date Pumping Recommended ❑ Yes � No Sludge Depth � ' Massachusetts Department of Environmental Protection � - Bureau of Resoure Protection - Titie 5 ; o !j DEP Approved tnspection and O&M Form for Title 51/A Treatment and Disposal Systems E. Field Testing Field Inspection: Color. ❑ Gray ❑ Brown � Clear ❑ Turbid ❑ Other(specify) Odor: � Musty ❑ Earthy ❑ Moldy ❑ Offensive ❑ Turbid Effluent Solids: � No ❑ Some pH 7.'I SU DO 0 mg/L Turbidity 0 NTU 6to 9 2 orgreater 40 orless Should a Remedial or General Use system fail the Field Testing,effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling information Samples Taken: ❑ Influent ❑ Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems 0.00 9Pd Parameters sampled:❑ pH ❑ BOD ❑ CBOD ❑ TSS ❑ TN ❑ Other(list below) Other i Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection &during this inspection: Conducted O&M.Checked the pumps and controls. Cleaned the spray nozzles and fan boxes. Field tested the effluent.Adjusted the EQ, pre-aeration and anoxic cycles. Recorded the settings. The system is operating properly. Notes and Comments Conducted O&M.Checked the pumps and controls. Cleaned the spray nozzles and fan boxes. Field tested the effluent.Adjusted the EQ, pre-aeration and anoxic cycles. Recorded the settings. The system is operating properly. , Massachusetts Department of Environmental Protection � i�," Bureau of Resoure Protection - Title 5 � DEP Approved lnspection and O&M Form for Title 5 I/A �, Treatment and Disposal Systems H. Certification 1 certify: I have inspected the sewage treatment and disposal system at the address above, have conducted the required Field Testing and/or sample collection in accordance with Standard Methods, have compieted this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I am a Massac usetts certified oper or in Gc rd nce with 257 CMR 2.00. o _ CY � � � Z�Z3/�y Operator Signature Date System owner must submit this report,technology O&M checklist, and any required sampling results to the local board of health as follows for each inspection performed: Remedial Use-by January 3151 of each year for the previous calendar year Piloting Use-within 45 days of inspection date Provisiortai Use-by March 315t of each year for the previous 12 months Generai Use-by September 3151 of each year for the previous 12 months Send to: Department of Environmental Protection Attention:Title 5 Program One Winter Street 5th Floor Boston, MA 02108 • - /S COASTAL ENGINEERING CO.,JNC. " 260 CRANBERRY HIGHWAY ORLEANS, MA 02653 TEL: 508 255-6511 FAX. (508 255-6700 - BIOCLERE FIELD REPORT- - -. _ Pro'ect No.: W Yq- �2 Date: 1 — Time:- - Installation: Tested:- ` - Client:- •� -- Service: Commissioned: Address; �_ �wtm�"! C : �S' Other. k � - Scheduled 0&M:y� lns ector: , �w _ ��u _ ° Biociere Model Number s 1 Odor around site? Y 1 Source of odor? - Check all that a I : - ' ` Miid: Medium: - - Strong: Musty: Se tic: - - . , 2 Take influenUeffluent sam les as re uired. � c'� l. � rv �, �lo r. t � ti�� o v t;t v �`. 3 a easure slud e in rima tanks and rease tra s as re uired: b Slud e'de th in rima fank: M,;:;: . Scum deptn: - Siud9e depth: ; _ , . c Does reaset�a need um m ? , . , <�.t-a,��k ' v � N . . UNIT 1 = UNIT 2 BIOCLERE VENTS a Is air assin throu h the vent? Y N / N If in doubt ut a smali lastic ba around vent and allow to fill. b Is the fan o eratin and in " ood condition� '' - N . > Y N GENERAL a An external dama e to the unit s ? If Yes, rovide details on back. Y Y / N b A�e cover, fan box and control anel securel locked? � N / N c An filter flies in the unit? v i fewl many : Y� fewi many Location of flies d Locks/ latches/ handles. OK? l N Y l N e Cid asket OK? - / N l:N Does the fan box contain standin water? Y � Y � If Yes, then remoVe water and clean drain holes if necessa . BIOMASS CHARACTERIZATION a Color of biomass? 1)white 2)white/gray 3)gray 4)gray/brown 5)brown 6}red/brown 7)black 8 other � b Thickness of biomass 6-12 inches below media surface. _ . ._ __ 1 li hf 2 medium 3 hea NOZZLE SPRAY PATTERN a Does s �a cover the entire surface area of inedia? v i N / N If not, ciean each nozzle with a bottle brush Does the s ra now cover the entire surface area7 Y / N Y / N If not then: 1 remove'noules and soak in a bieach solution 2 manuall en a e both dosin um s for two minutes 3 re lace nozzles Does the s ra now cover the entire surface area? Y / N Y / N If not, consult AWT Environmental, Inc. ' PUMPS AND CONTROL PANEL � a Record dosin and rec cle um timer settin s from control anel. Dosin Pum 1: min on:(o min off:Z min on: (� min off:� y Dosin Pum 2: min on:[p min off:�. min on:�� min aR:Z � RBC d2 PU�YI : min on: hrs off: min bn: hrs off: � In Bioclere control anei set dosin and rec cle timers to a test c cle: � a Am era e of dosin um 1: S, 6 amps amps � b Am era e of dosin um 2: amps amps r cAm era eofrec cie um : ,6 amps `o, amps 3 Are dosin um s alternatin ? �G l N i N Are the timers o eratin ro erl ? 1 N � N Visuall ins ect rela s for wear and record roblems below. ' if s are com onents are needed contact AWT if an ammeter.is not available,set the timers to a test cycle as above and at the Bioclere check the um s's o eration as follows: Dosin um s: check that um s are o eratin , alternatin and the Pump 1 OK? Y � N Pump � oK? Y i N d85i 118f@d f2St C Ci8 IS OCCUFfi� . Pump 2 OK? Y / N Pump 2 OK? Y / N OK? Y / N OK? Y ! N "If pumps or control components are not operating properly, record below And consult AWT Environmental, Inc. RESET TIMERS TO ABOVE SETTINGS: Note an chan es here: min on: min off: min on: min off: 'Do not chan e timers without consultin AWT Environmental, Inc. min on: min off: min on: min off: PLUMBING a Are the unions in the Bioclere leaking? Y i N v If es, then ti hten with i e wrench FINAL CHECK a Main ower"on" and set to le for all um s to "normal" osition. N N b Alarm to le set to the "ON" osition. v � y � c Lock control anei, Bioclere cover and fan 6ox. r/ � d if ossible, record the water meter readin : � REPORT SUMMARY: ^ �t ,..t w�l ob (cf• 4s n e/`�t / �L t9 a-�. — C .t G c I — (�� f �y � . � � .� � � IL < ; � e>A �C r M • �+ - .�f F1'L� � ,) t � r�i �b /'L SIGNATURE: D:IFORMSCurrentlTechServices � asiewaferlBioclereFieldReportdoc DISCNARGE MONITORING REPORT FORM PILdTiNG PERMIT No.: W033722 NAME OF pROJEC7: Shaw's Supermarket, Inc. FACILITY�QCATION: 1146 Route 28 South Yarmouth, MA DAFE SAMPLED: 12(912074 PARAMETER UNITS INFI.UENT PRE-AERATION EFFLUENT pH pH units 7.3p Flow(avg. dail gpd 2 6�$ Bdd$ mglL GSOQs my/� TSS m /L TKN m fL 4.00 Nitrite-N m (L <0.406 Nitrate-N m /L 0.2g Tofal Nitro en �g(� &�g Ammonia-N mg/L REMAftlfS: Effluent grab samp(es are coilected from the pump chamber after the anoxic denifrification tank.The fesi resuifs show qood sysfem performance. Ol�DoclW1WYA4Q2448roclere Testing4Snmmary.xls I- - �/6/ay ENVIROTECHLABORATORIES, INC. MA CERT. NO.: M—MA 063 � 8 Jan Sebastian Drive R E C E I V E D Sandwicl:,MA 02563 (508)888-6460 1-800-339-6460 �p� 02 ��5 FAX(508)888-6446 Friday,ne�e�er iv,zota � Coastal Engineering Co., inc. Coasta[Engineering Co. 260 Cranberry Highway Orleans MA 02653 ProjectName: SHAWS Carnmer¢ts: Project Number: WYA 024 Col[ection Date: 12/09/14 Collection Time: 10:00 Sampled By: SKM Lab Order Number: PVW-14�083 Date Received: 12/09/19 ., '�'�-Sa�� S�le-9}me �� SanipleDaf¢�.� �y �� :�� =� Gomme f- ` .�`-� � . � � =�z�� , ,� � ' �, EfFlue 1p0 � � ,�7 9/14�`'� � �"�'* � "c-:> . . ._ ._ � ^t.4��- _ ,... .,:f,�;a��h 5 �� ``V .�...- _...c�`x`. . -:._..;�, n �..;, � Paramefers Unifs Test Ruu(is RepoKab[e Limifs D¢te Anatyzed Analyst � Method � Kjeldhal Nitrogen � mg/L 4.0 0.6 �2nsna KB SM4500 NH3 C � Nitrete-N . mg/L A29 . 0.01 . . �vo9/1a LL 300.0 � Nitrite-N mg/L BRL 0.006 tvoelt4 LL . 300.0 BRL=below repor[ab[e[imits *see anached � � By: Ron d J. S r' Laboratory ' ectar Page 1 of 1 OASTAL CHAIN OF CUSTODY RECORD N��v�'��vv Lab Contact: Ronald J, Saari 260 Cranberry Highway Orleans,MA 02653 Q�Q�� TC. 508.255.6511 FAX:508.255.6700 Company: Envirotech Laboratories Inc. Address: 8 Jan Sebastian Drive. Unit 12 Projed Name: S�na�'I Sandwich MA 02563 Project No.: W`(J�- �� Telephone: 508-888-6460/800-339-6460 Fax:508-888-6446 Sampled By: _J�.�d�1 (piease print) Containers �; x � � o_•c Dateffime Sample Identification No. Size G/P t7 �j N � Presrv. Analysis RequestedfComments Lah Number rR a (y , /v(} �{�[u<ni�- 1 a�S�� DC W� C ��( �°Z � /,Iv3 �!�-/yya�"3 ct ci U �9 �� `�� " u . ��,L,SCJ. ��/V Sampled/Ftelin s ed by: DatelrTime f2ec ' d y: D e/T�'me Relinquished by: Date/Time i��f�y �"� g/'`� J / i nature 3''� ature JS� (Si_4nature) Relinquished by: `�" Date(fime Received by: DatefCime Relinquished by: Date/Time Si nature Si nature Si nature Method of Shipment Remarks ❑ US Express Mail Label No: ❑ Other. � � � D;IFORMSITechServices-Was�e+naterlChainoJCuslady-Cnviroted�l0-24-D3.doc