HomeMy WebLinkAboutMiscellaneous - 115 SUTTON HILL ROAD 4/30/2018 K_ oad
1 115 SUTTON HILL ROAO-
210,'OSO�0000.0
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Commonwealth of Massachusetts
_ C"tylTown of North Andover
System Pumping Record
Form 4
wy
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
provided here. Before
information must be substantially the same as that Record(must be s bmitted o
local Board of Health to determine the form they use.The System Pumpingg date in
the local Board of Health or other approving authority within 14 days from the pumping
accordance with 310 CMR 15.351.
A. Facility information
Important When
1. System Location:
filling out forms Y ��,�,.. SOK
on the computer, '
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover State Zip Code
use the return City/Town
key.
toQ 2. System Owner:
Name
mran
Address(if different from location)
State Zip Code
CityTowh
Telephone Number
B. Pumping Record Jbcy'y
2. Quantity Pumped: Gallons
1. Date of Pumping Date haLq__
Ti ht Tank ❑ Grease Trap
. 3. Type of system: ❑ Cesspool(s)
Septic Tank ❑ g
❑ Other(describe):
If. es,was it cleaned? ❑ Yes E] No
4. Effluent Tee Filter present? ❑ Yes ❑ No Y
5. Condition of System:
6. System P m ed By:
Vehicle License Number
Name
St s Septic Service
Company
7. Location where contents were disposed: Ii.
A
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
\ •%'-
ate
Signature of Receiving Facility
Dt�
System Pumping Record-Page
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•'•t i••••..,ir,;',\'�� IDEp.haa proy1M,Wv.forrii(or wo by local Boafda of Health. Other forms may oa V3 00, out ine
Informillon mu:l.,be fobs.W11a11y the some as that provlded here, Before valnQ thla form, check w In yc.
IOCaf 60�rd,Qf Hoole !q'do,lo,rmine the form Ihey use. The System Pumping Record mv_at.be.s,vom uec ,c
the local eoprd.o(Health or other approving authority,
X—Fac111ty.Informdtton
,. ' . . ' , OCT 1 2 2006
V out 1, Syslem Locallon; -_IR
farm m!M . -.
ew 0.4y
Mill,
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. �iv'11la �1�11,x. ,' •.:•,.�;,��K;;I!�'i,?a;�1C'�;..dj�i�, '
3yslern Owner' `
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Telephone Nvmolr
• � � ' .� �, Pump,l.ng�''�acord •
7vd q
1, 'vale pf,Pumpinp d+t, 2, OuentIly Pumped:
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3) ❑ Se
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Efflusnl71•1 Fl1[ar:proionl?•'L7 Yes ❑ No If Y0.1, was Il cleaned? CD Yes ❑ No
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8, Syslom Pvmpod By, r
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Y ar$►,� pyy gR ,��Dit�ss TOWN OF NORTH A.NOOVER
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s°c,�oa �... FLOODED�4LiDCAIVBYOYAR MER EXPL„{iN
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
Sl S l'E:ti1 OWNER & ADDRESS S YSTEM LOCATION
(example: left front of house
DA"I'E OF PUMPING: QUANTITY PUMPED GALLONS
CI SSPOOL: NO YES SEPTIC TANK: NO YES !/
N:- 'TLJRE OF SERVICE: ROUTINE // EMERGENCY
U13SFR V:1Tl0NS:
('OOD CONDITION FULL TO C 0V -,'R
1-lf'AVY GREASII. BAFFLES IN PLACE
ROOTS LEACI-IFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
Cu�I�I r�:tirs:
(_�ONTL' NTS TRANSFERRED TO:
SEPTIC SYSTEM INSPECTION FORM
ADDRESS I S So `hv" 14111
DATE INSPECTED:
PROPERLY FUNCTIONING? �Y N
WEATHER CONDITIONS
COMMENTS :
WATlER aI;ALI Y TES Ti
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
i
RECEIVED
TOWNX
.TH ANDOVER OCT 0 5 2004 '
SYSTEM 'IN�; }�FCORI..�
UAIk
TORE LTH NORTH
EPAR IM NTE
SYSTE OWNER & ADDRESSYSTFM-LOCATION
L
DATE, OF PLJMPINO: ---.
PUMPED:
Ck s5f'OUL: NO_........ YES SOP6c Tarzk: NO_ YES
NA FURS OF SERVICE: itUU CINE: V
08SER VATIONS: /FULL 'r)C)
GOODCONDITION (;OYER
HEAVY GREASE BAFFLES IN PLACE
ROOTS _..___
LEACHMEL
EXCESSIVE SOLIDS FLOODED p RUNBACK
SOLID CARRYOVER,..,.,, OTHER 'EXPLAIN .
Syatcm PWnpcd by ,
.-.rfa.
t:UMMEN'TS
i
CUN I EN 1'S I'KANSFERRED 1-0
it
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WATERSHED RESIDENTS QUESTIONNAIRE
1. Name �/►'E,DC/�l�K it/ �FP� -
2. Street Address SU 7,'rOA/ H/LG /fa
F
3. How many members are in your household? 2-
4. What type of sewage disposal system do you have?
❑ cesspool
Vseptic tank and leaching area
❑ connection to municipal sewer
❑ other (describe)
❑ do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health?
Cly' yes ❑ no ❑ do not know•.:
6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years •
® over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
P yes ❑ no ❑ do not know
If yes, approximately how long ago? (9 -7 years. What was done?
8. How frequently is your sewage disposal system pumped out? ❑ annually
every 2-4 years ❑ every 5-10_years. ❑ over 10 years ❑ never
-� 9. Have you had any problems with your sewage disposal system? ❑ yes 9?'*"no
If yes, what problems? -
❑ repeated pump-outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. How many of each appliance are connected to your sewage disposal system?
washing machine dishwasher _iZ— garbage disposal
dehumidifier drain sump pump toilet
roof/pavement drains shower/bathtub t,-
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher A-l h Svb G14
T
clotheswasher �� d
12. Does your property have a lawn? V yes ❑ no
If yes, approximately what size?
("less than 1/4 acre .El 1/4 acre ❑ 1/z acre ❑ 3/4 acre ❑ 1 acre
❑ more than 1 acre (Specify) acres
13. How often do you fertilize your lawn?
No. of applications per year
Season(s) of the year S.diP/�C-
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
SC0-rTS 06VIA PC&
❑ Check here if your lawn is maintained by a professional landscape contractor.
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protectionw
BVI CPQ �g
William F.Weld �,O
Governor �
Trudy Coxe
se
Sntary,EDEA \
David B. Struhs
Commiafoner N tt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ;
/ CERTIFICATI N
Property Address: ✓ #1 l / kyr a ��✓
Address of Owner:
Date of Inspection: 9_ - f L (If different)
Name of Inspector:
Company Name, Address and Telephone Number:
5T c wj6v41 4,"o I o w S e p� • � '� �E3/t- j2 0 4 d S T ��/>r ti cb�+f(� ���
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CERTIFICATION
ION 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 sfI 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, B, C, or D:
A) 5YSTEM PASSES:
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.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components kneetto be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain whys not)
The septic tank is metal, 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.
(revised 8/15/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500
i4)Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued)
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):
broken pipe(s)are replaced
obstruction is removed
f y' 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
Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
i •
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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: I`
The system has a seppiic tank and soil absorption system and is within 100 fee! to a surface water supply or tributary to a
surface water supply. \
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and 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.
D) SYSTEM FAILS: A,
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.
Backup of sewage into facility 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.
(revised 8/15/95) 2
t1
.1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: ��
Date of Inspection: q,fj` P—Q'-
D] SYSTEM FAILS (continued): W. 0.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 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.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. 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.
E] LARGE SYSTEM FAILS: N. A
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 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:
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.
(revised 8/15/95) 3
r
1
r
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
�f N. A140pvev
Property Address: /�� �U �"�0 A-1 /� � � /
Owner:
Date of Inspection: _�l� / �Q 0 e
Check if the folll wing have been done:
Wiping information was requested of the owner, occupant, and Board of Health.
t ✓,/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
/dining that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
X
uilt plans have been obtained and examined. Note if they are not available with N/A.
ZThacility or dwelling was inspected for signs of sewage back-up.
_Tsystem does not receive non-sanitary or industrial waste flow
T,he site was inspected for signs of breakout.
_ZAll 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
Mees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/_T e size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
_The facility ov ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
�^� r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
��//
SYSTEM INFORMATION
Property Address: // ,s7o-iA✓�/ r�� A 0 V e✓
Owner:
Date of Inspection:
(/ FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms:
Number of current residents: 11-01,
Garbage grinder (yes or no):
Laundry connected to system ( es or no):�
Seasonal use (yes or no):
Water meter readings, if available:
Last date of occupancy:�CG
COMMERCIAUINDUSTRIAL: i
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occurancy:
OTHER: (Describe) /
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no) -e
If yes, volume pumpedallons
Reason for pumping: �� T'd I�L +-/g4/`Ye6P S 4 4n pis 5'
TYPE O STEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: �O
Sewage odors detected when arriving at the site: (yes or no)J/0
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 S U /y/ ` �,• �(� U
Owner:
Date ofInspection:q,lA_�� �Y
TIGHT OR HOLDING TANK:_ /�C
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:�'p S
(locate on site plan)
Depth of liquid level above outlet invert:--1t(1o�
Comments:
(note if level and distributor i equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
Pa
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 6/15/95) l 7
i
y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
S
/ SYSTEM (INFORMATION (continued)
Property Address: 1 S- "'
Owner: • /
Date of Inspection:
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:_
leaching galleries, number:
leaching trenches, number,length: ��
leaching fields, number, dimensions: V
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS:
(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:_
(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.)
(revised 8/15/95) 8
Commonwealth of Massachusetts'
_ . City/Town of No Andover
System Pumping Record
Form 4
Y
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab Si
key to move your Address
cursor-do not
No Andover
use the return Mai• u '
j.
key. City/Town State
Zip Code
2. System Owner: Nov
Q/1)
Name r TOWN OF NORTH AiJUOV«R k
scan HEALTH Utr-rlF
Address(if different from location)
City/Town State
Zip Code
Telephone Number
B. Pumping Record r
1. Date of Pumping - to G 16 2 j o eo
Date Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
SrPx-
6. System Pumped=By':
Name' Vehicle License Number
aff:'S Se eNICe
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06
System Pumping Record•Page 1 of 1
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /�j J G .0y
Owner: f��4 U
Date of Inspection: //9�-C,
s
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
�- 3
J�
� f _
l3-
DEPTH TO GROUNDWATER
Depth to groundwater: '' f feet
method of determination or approximation: L.--T Gl e At Gt.I T tf
(revised 8/15/95) 9
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• �� . , �I:r. DEPr,ha: provided Yt�,l, ,•,:!;� , . C .. . ,
>;hli form for use by local B ards 0 �CI V�i®gyst m Pum I
ba submletl to the.local'Board of Health oro P ng Record m s
r: C;r;,•. :a' ;',.,i;':,,;:;.,r;s ,;,, t er ap rovins authority,
A Facility lnforri'1ation
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Sytlem PumPIn9 Record Pale 1 1
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Commonwealth of Massachusetts
u u City/Town of No.Andover
W° System Pumping Record
Form 4
41M SVOy`ew
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days fr �txt i, date-in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Locatio TOWN OF NORTH ANDOVIR
forms on the I 4
f 141ALTH DEPARTIVIONT
computer,use 1
only the tab key Address `
to move your No Andover Ma
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
t� pio tt
Name
as S> *u,�
Address(if different from Mit, n)
r
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity P
N ' y D e Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
�- _ — — ---
Y ._
-X
6. S stem Pump d B
Tn
arae Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
S s Pre-treatmenLPjant, 20 So. Mill Bradford, Ma 01835
Vi. e of auYr' ,', Date ) ( - So
Signature of Receiving F i yDate �/
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