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HomeMy WebLinkAboutMiscellaneous - 1296 OSGOOD STREET 4/30/2018 (2) 31/ 43 LAMassachusetts Department of Environmental-Protection- Industrial nvironmental-P-r-otection -- - Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name Important` A. FacilityInformation When filling out forms on the computer,use Mandolin Hair Salon 7231 only the tab key a. Facility Name b. Facility SIC Code c.DEP Assigned Facility ID to move your 1296 Osgood Street 2nd Floor cursor-do not d.Facility Site Address(Street No.,Street Name,Street Suffix e.g.St,Ave,etc.) e.Secondary Unit(e.g.Building-C,7th Floor) use the return key. North Andover MA 01845 f.City g.State h.Zip Code r� 1296 Osgood Street 2nd L Facility Mailing Address(If different from the facility site address above) j.Secondary Unit North Andover MA 01845 k.City I.State m.Zip Code 978-697-5380 58-2678675 n.Phone Number o.Fax Number p. Federal Employer Identification Number(FEIN or EIN) A-I. Certification Information Wendy Forgetta Owner 978-697-5380 a.Contact Person First Name b.Contact Person Last Name c.Title d.Telephone Number Wendy Forgetta Owner 978-697-5380 e.Owner First Name f.Owner Last Name g.Title h.Telephone Number i.General business description B. Industrial Wastewater and Holding Tank Information Answer all questions, unless you are directed to skip a question. Do not answer questions that you are directed to skip. 1. Major sources of industrial wastewater a. ❑ Process wastewater (Check all that apply) b. ❑ Equipment cleaning wastewater c. ❑ Spent concentrated solution d. ❑ Floor spills or floor drainage e. ® Other(s)(Please describe below) Hair Treatment Describe major sources 2. Major pollutants in the industrial wastewater a. ❑ BOD/COD (Check all that apply) b. ❑ Oil &Grease c. ❑ Low/High pH d. ❑ Cyanide e. ❑ Cadmium f. ❑ Chromium Ml g. ❑ Copper R��' ' '' h. ❑ Lead i. ❑ Nickel MAY 2 3 on j• El Silver k. El Zinc I. ® Other(s) (Please describe below) TOHEALTH Lc --— Hair Color& Perm Products Describe major pollutants Edep01.doc 12/02 - Page 1 of 6 - --Massachusetts Department of Environmental Protection Ll Industrial Wastewater Holding Tank Compliance Certification Form DEP01 DEP Assigned FacilitylDor P1 � ) Facility Name � I B. Industrial Wastewater and Holding Tank Information (Cont.) 3. Holding Tank ID (If any): 4. Holding Tank Installation Date: (MM/DD/YYYY) 5. Tank Type (Check one box only): a. ❑ Above-ground b. E In-ground 6. Tank Construction Material a. Steel (Check appropriate box(es)or specify): b. E Concrete c. E Fiberglass d. ❑ Plastic e. ❑ Other(s) (Please describe below) Fiberglass Primary/Concrete Containment Describe construction material 7. Tank Capacity a. E Less than 3,000 gallons (Check one box only): b. ❑ 3,000 gallons or more B-I. Compliance Information Section-1 General 101 Do you discharge industrial wastewater to ❑ yes—you must cease discharging and a septic system, leaching field, or complete a Return to Compliance Plan cesspool? E no 102 Do you discharge industrial wastewater to ❑ yes—you must cease discharging and a storm drain or to the ground without a complete a Return to Compliance Plan surface water or groundwater discharge permit? E no 103 Is the discharge of your industrial ❑ yes— I have checked with DEP and I am wastewater to a municipal sewer system aware of the restrictions that may apply to feasible? my facility (if your answer is yes to this question, you need to check with DEP for restrictions ® no that may apply to your facility before completing this certification) Edep01-.doc-12/02— —- _- -- — Page 2 of 6 ' . -- - - Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank Compliance Certification Form DEP01 LlDEPa ed FacilitylDor p � ) FacilitytyName I I B-I. Compliance Information (Cont.) 104 Is your facility located in the Zone I or ❑ yes— I have checked with DEP and I am Zone A of a drinking water supply area? aware of the restrictions that may apply to (if your answer is yes to this question, you my facility need to check with DEP for restrictions that may apply to your facility before ® no completing this certification) 105 Is this certification for an above-ground ❑ yes holding tank? ® no -skip to question 301 Section-2 Above-Ground Holding Tank 201 Is this above-ground holding tank ❑ yes constructed or lined with material compatible with your industrial ❑ no -submit a Return to Compliance Plan wastewater? 202 Is this above-ground holding tank ❑ yes remotely filled or automatically filled? ❑ no-skip to question 203 202a Have you provided an appropriate ❑ yes audio and light alarm system for this above-ground holding tank? ❑ no-submit a Return to Compliance Plan 203 Have you provided appropriate spill ❑ yes containment for this above-ground holding tank? ❑ no-submit a Return to Compliance Plan 204 Have you provided "Non-Hazardous ❑ yes Industrial Wastewater' labels for this above-ground holding tank? ❑ no-submit a Return to Compliance Plan 205 Was this above-ground holding tank both ❑ yes installed after November 15, 2002 and fabricated on site? ❑ no - skip to question 401 I — —Odep01.doc-1-2/02 ------ -- - Page 3 of 6-11111 LlMassachusetts Department of Environmental Protection - Industrial Wastewater Holding Tank Compliance Certification Form DEP01 DEP FacilityssignedFacilitylDor Name i B-I. Compliance Information (Cont.) 205a Was this above-ground holding ❑ yes —skip to question 401 tank constructed in accordance with engineering plans that were ❑ no—submit a Return to Compliance Plan stamped and signed by a and skip to question 401 Massachusetts Registered Professional Engineer? Section-3 In-Ground Holding Tank 301 Is this in-ground holding tank constructed ® yes or lined with material compatible with your industrial wastewater? ❑ no -submit a Return to Compliance Plan 302 Is the capacity of this in-ground holding ® yes tank greater than 500% of the average daily flow? ❑ no -submit a Return to Compliance Plan 303 Have you provided an appropriate audio ® yes and light alarm system for this in-ground holding tank? ❑ no-submit a Return to Compliance Plan 304 Have you provided "Non-Hazardous ® yes Industrial Wastewater' labels or signs for this in-ground holding tank? ❑ no-submit a Return to Compliance Plan 305 Was this in-ground holding tank installed ❑ yes before November 15, 2002? ® no-skip to question 306 305a Was this in-ground holding tank ❑ yes -skip to question 401 constructed in accordance with engineering plans that were ❑ no stamped and signed by a Massachusetts Registered Professional Engineer? ---- - Odep01.doc 12/02 Page 4 of 6 • Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name B-I. Compliance Information (Cont.) 305b Will you (or did you)obtain an ❑ yes - skip to question 401 - integrity assessment by November 15, 2003, which will be ❑ no - submit a Return to Compliance Plan prepared by a Massachusetts and skip to question 401 Registered Professional Engineer, for this in-ground holding tank? 306 Was this in-ground holding tank ® yes constructed in accordance with engineering plans that were stamped and ❑ no- submit a Return to Compliance Plan signed by a Massachusetts Registered Professional Engineer? 307 Have you provided an appropriate ® yes secondary containment for this in-ground holding tank? ❑ no - submit a Return to Compliance Plan Section-4 Record Keeping 401 Do you maintain all holding tank ® yes construction and installation records (including all applicable permits)at the ❑ no -submit a Return to Compliance Plan facility? 402 Do you keep and maintain the appropriate ® yes operating records, including wastewater shipment, ultimate destination, and hauler ❑ no -submit a Return to Compliance Plan information at the facility? EdepOl.doc 12/02- - — - Page 5 of 6 - - Massachusetts Department-of-Environmental Protection Ll Industrial Wastewater Holding Tank Compliance Certification Form DEPO1 DEPAsNigned Facility ID or p � � Facility Name C. Certification Statement (Note: Complete all required Return to Compliance Plan forms before signing this statement) "I,Wendy Forgetta , attest under the pains and penalties of perjury: (Name of responsible official) (i) that I have personally examined and am familiar with the information contained in this submittal, including any and all documents accompanying this certification statement; (ii) that, based on my inquiry of those individuals responsible for obtaining the information, the information contained in this submittal is to the best of my knowledge, true, accurate, and complete; (iii) that systems to maintain compliance are in place at the facility and will be maintained even if processes or operating procedures are changed; and (iv) that I am fully authorized to make this attestation on behalf of this facility. am aware that there are significant penalties including, but not limited to, possible fines and imprisonment for willfully submitting false, inaccurate, or incomplete information." t Signature Date(MM/DD/YYYY) Wendy Forgetta Owner Printed Name Title Source of Signatory Authority(Check appropriate box): 1. If a Corporation: a. ❑ President b. ❑ Secretary c. ❑ Treasurer d. ❑ Vice President(if authorized by corporate vote) e. ❑ Representative of the above (if authorized by corporate vote and if responsible for overall operation of the facility) 2. If a Partnership: ❑ General Partner 3. If a Sole Proprietorship: E Proprietor 4. If an Institution: ❑ Principal Executive Officer 5. If a Municipality or a Public Agency: a. ❑ Principal Executive Officer b. ❑ Ranking Elected Official (Empowered to enter into contracts on behalf of the municipality or public agency) Edep01.doc-12/02 - -- Page 6 of 6 ■ MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS LVI 66 PARK STREET•ANDOVER,MASSACHUSETTS 01810•TEL(978)475-3555,373-5721 •FAX(978)475-1448•E-MAIL:merreng@aol.com April 20, 2006 77-1 Ms. Susan Sawyer Public Health Director A P R , 0 2006 400 Osgood Street North Andover,MA 01845 1 Re: 1292 Osgood St Dear Ms. Sawyer: We have received your review letter dated April 19,2006 regarding the above referenced site. With regard to item#1,we have revised the plan to reflect the location of T-3 &T-4. We respectfully request the North Andover Board of Health approve the use of these test pit results as they are more than 2 years old, and are consistent with recently conducted test pit#5. With respect to item#2 of your letter, we ask that you approve the design as re-submitted,with the condition that a non hazardous industrial waste holding tank permit is filed for and obtained and that no request for a construction permit will be made by our client until this, and all other necessary permits are obtained. Lastly,with regards to item#3 of your letter, since the existing system is only a few years old, and since construction of the existing system required substantial sand fill,we feel it is unnecessary to remove existing suitable sand fill only to be replaced with similar sand fill. Also since both the North Andover Board of Health and the design engineer conduct excavation inspections during the normal course of a system installation, we could collectively agree upon the extent of the sand removal during this inspection as the extent of spoiled soils is typically very evident on systems this new. We appreciate your consideration of this matter and look forward to discussing these issues, and others related to this design at your earliest available meeting agenda. Very truly yours, MERRIMACK ENGINEERING SERVICES William Dufrense Project Manager tl MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS LAND SURVEYORS PLANNERS 66 PARK STREET•ANDOVER,MA 01810•(978)475-3555,373-5721 •FAX(978)475-1448 •E-MAIL info@merrimackengineering.com May 23, 2006 Ms. Susan Sawyer: ' Public Health Director 1600 Osgood Street Building 20, Suite 2-36 MAY 2 3 2006 North Andover, MA 01845 Re: 1296 Osgood Street/Beauty Salon g Y Dear Ms. Sawyer: We are working with Wendy Forgetta regarding the above referenced project. Pursuant to 310 CMR 18.00,permits are not required for installation of an industrial waste holding tank. The current procedure requires the applicant to install a holding tank consistent with the new regulations and then submit a Compliance Certification Form (DEPO1) certifying compliance with DEP regulations. Attached is a copy of this application which will be submitted to DEP upon completion and installation of the holding tank. We hope this information will be helpful in your evaluation of the pending septic approvals. Very truly yours, MERRIMACK ENGINEERING SERVICES William Dufresne Project Manager ti Massachusetts Department of Environmental Protection Ll Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name Important: A. FacilityInformation When filling out forms on the computer,use Mandolin Hair Salon 7231 only the tab key a.Facility Name b. Facility SIC Code c.DEP Assigned Facility ID to move your 1296 Osgood Street 2nd Floor cursor-do not d.Facility Site Address(Street No.,Street Name,Street Suffix e.g.St,Ave,etc.) e.Secondary Unit(e.g.Building-C,7th Floor) use the return key. North Andover MA 01845 f.City g.State h.Zip Code r� 1296 Osgood Street 2nd I. Facility Mailing Address(If different from the facility site address above) j.Secondary Unit North Andover MA 01845 n k.City I.State m.Zip Code 978-697-5380 58-2678675 n.Phone Number o.Fax Number p.Federal Employer Identification Number(FEIN or EIN) A-I. Certification Information Wendy Forgetta Owner 978-697-5380 a.Contact Person First Name b.Contact Person Last Name c.Title d.Telephone Number Wendy Forgetta Owner 978-697-5380 e.Owner First Name f.Owner Last Name g.Title h.Telephone Number I.General business description B. Industrial Wastewater and Holding Tank Information Answer all questions, unless you are directed to skip a question. Do not answer questions that you are directed to skip. 1. Major sources of industrial wastewater a. ❑ Process wastewater (Check all that apply) b. ❑ Equipment cleaning wastewater c. ❑ Spent concentrated solution d. ❑ Floor spills or floor drainage e. ® Other(s) (Please describe below) Hair Treatment Describe major sources 2. Major pollutants in the industrial wastewater a. ❑ BOD/COD (Check all that apply) b. ❑ Oil &Grease c. ❑ Low/High pH d. ❑ Cyanide e. ❑ Cadmium f. ❑ Chromium g. ❑ Copper h. ❑ Lead i. ❑ Nickel M 2. j. ❑ Silver AY k. ❑ Zinc I. ® Other(s)(Please describe below) Hair Color& Perm Products Describe major pollutants Ndep01.doc 12/02 Page 1 of 6 i r Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name B. Industrial Wastewater and Holding Tank Information (Cont.) 3. Holding Tank ID (If any): 4. Holding Tank Installation Date: (MM/DD/YYYY) 5. Tank Type (Check one box only): a. ❑ Above-ground b. ® In-ground 6. Tank Construction Material a. ❑ Steel (Check appropriate box(es)or specify): b. ® Concrete c. ® Fiberglass d. ❑ Plastic e. ❑ Other(s) (Please describe below) Fiberglass Primary/Concrete Containment Describe construction material 7. Tank Capacity gallons P Y a. ® .Less than 3�000 (Check one box only): b. ❑ 3,000 gallons or more B-I. Compliance Information Section-1 General 101 Do you discharge industrial wastewater to ❑ yes—you must cease discharging and a septic system, leaching field, or complete a Return to Compliance Plan cesspool? ® no 102 Do you discharge industrial wastewater to ❑ yes—you must cease discharging and a storm drain or to the ground without a complete a Return to Compliance Plan surface water or groundwater discharge permit? ® no 103 Is the discharge of your industrial ❑ yes— I have checked with DEP and I am wastewater to a municipal sewer system aware of the restrictions that may apply to feasible? my facility (if your answer is yes to this question, you need to check with DEP for restrictions ® no that may apply to your facility before completing this certification) ■dep0l.doc 12/02 -- Page 2 of 6 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name B-I. Compliance Information (Cont.) 104 Is your facility located in the Zone I or ❑ yes— I have checked with DEP and I am Zone A of a drinking water supply area? aware of the restrictions that may apply to (if your answer is yes to this question, you my facility need to check with DEP for restrictions that may apply to your facility before ® no completing this certification) 105 Is this certification for an above-ground ❑ yes holding tank? ® no -skip to question 301 Section-2 Above-Ground Holding Tank 201 Is this above-ground holding tank ❑ yes constructed or lined with material compatible with your industrial ❑ no -submit a Return to Compliance Plan wastewater? I I 202 Is this above-ground holding tank ❑ yes remotely filled or automatically filled? ❑ no-skip to question 203 202a Have you provided an appropriate ❑ yes audio and light alarm system for this above-ground holding tank? ❑ no-submit a Return to Compliance Plan 203 Have you provided appropriate spill ❑ yes containment for this above-ground holding tank? ❑ no-submit a Return to Compliance Plan 204 Have you provided "Non-Hazardous ❑ yes Industrial Wastewater" labels for this above-ground holding tank? ❑ no-submit a Return to Compliance Plan 205 Was this above-ground holding tank both ❑ yes installed after November 15, 2002 and fabricated on site? ❑ no-skip to question 401 ■dep01.doc 12/02 Page 3 of 6 M IL Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name B-I. Compliance Information (Cont.) 205a Was this above-ground holding ❑ yes —skip to question 401 tank constructed in accordance with engineering plans that were ❑ no—submit a Return to Compliance Plan stamped and signed by a and skip to question 401 Massachusetts Registered Professional Engineer? Section-3 In-Ground Holding Tank 301 Is this in-ground holding tank constructed ® yes or lined with material compatible with your industrial wastewater? ❑ no-submit a Return to Compliance Plan 302 Is the capacity of this in-ground holding ® yes tank greater than 500% of the average daily flow? ❑ no -submit a Return to Compliance Plan 303 Have you provided an appropriate audio ® yes and light alarm system for this in-ground holding tank? ❑ no- submit a Return to Compliance Plan 304 Have you provided"Non-Hazardous ® yes Industrial Wastewater" labels or signs for this in-ground holding tank? ❑ no-submit a Return to Compliance Plan 305 Was this in-ground holding tank installed ❑ yes before November 15, 2002? ® no-skip to question 306 305a Was this in-ground holding tank ❑ yes-skip to question 401 constructed in accordance with engineering plans that were ❑ no stamped and signed by a Massachusetts Registered Professional Engineer? ■depol.doc 12/02 Page-4 of 6 S Massachusetts Department of Environmental Protection Ll Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name B-I. Compliance Information (Cont.) 305b Will you (or did you)obtain an ❑ yes - skip to question 401 integrity assessment by November 15, 2003, which will be ❑ no-submit a Return to Compliance Plan prepared by a Massachusetts and skip to question 401 Registered Professional Engineer, for this in-ground holding tank? 306 Was this in-ground holding tank ® yes constructed in accordance with engineering plans that were stamped and ❑ no -submit a Return to Compliance Plan signed by a Massachusetts Registered Professional Engineer? 307 Have you provided an appropriate ® yes secondary containment for this in-ground holding tank? ❑ no - submit a Return to Compliance Plan Section-4 Record Keeping 401 Do you maintain all holding tank ® yes construction and installation records (including all applicable permits)at the ❑ no -submit a Return to Compliance Plan facility? 402 Do you keep and maintain the appropriate ® yes operating records, including wastewater shipment, ultimate destination, and hauler ❑ no-submit a Return to Compliance Plan information at the facility? MdepOl.doc 12/02 Page 5 of 6 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or ILI Compliance Certification Form (DEPO1 ) Facility Name C. Certification Statement (Note: Complete all required Return to Compliance Plan forms before signing this statement) "I, Wendy Forgetta , attest under the pains and penalties of perjury: (Name of responsible official) (i) that I have personally examined and am familiar with the information contained in this submittal, including any and all documents accompanying this certification statement; (ii) that, based on my inquiry of those individuals responsible for obtaining the information, the information contained in this submittal is to the best of my knowledge, true, accurate, and complete; (iii) that systems to maintain compliance are in place at the facility and will be maintained even if processes or operating procedures are changed; and (iv) that I am fully authorized to make this attestation on behalf of this facility. I am aware that there are significant penalties including, but not limited to, possible fines and imprisonment for willfully submitting false, inaccurate, or incomplete information." Signature Date(MM/DD/YYYY) Wendy Forgetta Owner Printed Name Title Source of Signatory Authority(Check appropriate box): 1. If a Corporation: a. ❑ President b. ❑ Secretary c. ❑ Treasurer d. ❑ Vice President(if authorized by corporate vote) e. ❑ Representative of the above(if authorized by corporate vote and if responsible for overall operation of the facility) 2. If a Partnership:- -- ❑ General Partner 3. If a Sole Proprietorship: E Proprietor 4. If an Institution: ❑ Principal Executive Officer 5. If a Municipality or a Public Agency: a. ❑ Principal Executive Officer b. ❑ Ranking Elected Official (Empowered to enter into contracts on behalf of the municipality or public agency) MdepOl.doc 12/02 Page 6 of 6 e MERRIMACK ENGINEERING SERVICES, INC, PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET•ANDOVER,MASSACHUSETTS 01810•TEL(978)475-3555,373-5721 •FAX(978)475-1448•E-MAIL:merreng@aol.com April 20, 2006 1 Ms. Susan Sawyer ! Public Health Director APR 2 2006 400 Osgood Street North Andover,MA 01845 I x)wE R Re: 1292 Osgood St Dear Ms. Sawyer: We have received your review letter dated April 19, 2006 regarding the above referenced site. With regard to item#1, we have revised the plan to reflect the location of T-3 &T-4. We respectfully request the North Andover Board of Health approve the use of these test pit results as they are more than 2 years old, and are consistent with recently conducted test pit#5. With respect to item#2 of your letter,we ask that you approve the design as re-submitted, with the condition that a non hazardous industrial waste holding tank permit is filed for and obtained and that no request for a construction permit will be made by our client until this, and all other necessary permits are obtained. Lastly,with regards to item#3 of your letter, since the existing system is only a few years old, and since construction of the existing system required substantial sand fill, we feel it is unnecessary to remove existing suitable sand fill only to be replaced with similar sand fill. Also since both the North Andover Board of Health and the design engineer conduct excavation inspections during the normal course of a system installation,we could collectively agree upon the extent of the sand removal during this inspection as the extent of spoiled soils is typically very evident on systems this new. We appreciate your consideration of this matter and look forward to discussing these issues, and others related to this design at your earliest available meeting agenda. Very truly yours, MERRIMACK ENGINEERING SERVICES William Dufrense Project Manager ti 1 MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS LAND SURVEYORS PLANNERS 66 PARK STREET•ANDOVER,MA 01810•(978)475-3555,373-5721 •FAX(978)475-1448• E-MAIL info@merrimackengineering.com May 23, 2006 Ms. Susan Sawyer:: Public Health Director 1600 Osgood Street Building 20, Suite 2-36 MAY 2 2006 North Andover, MA 01845 Re: 1296 Osgood Street/Beauty Salon Dear Ms. Sawyer: We are working with Wendy Forgetta regarding the above referenced project. Pursuant to 310 CMR 18.00,permits are not required for installation of an industrial waste holding tank. The current procedure requires the applicant to install a holding tank consistent with the new regulations and then submit a Compliance Certification Form (DEP01) certifying compliance with DEP regulations. Attached is a copy of this application which will be submitted to DEP upon completion and installation of the holding tank. We hope this information will be helpful in your evaluation of the pending septic approvals. Very truly yours, MERRIMACK ENGINEERING SERVICES LIU William Dufresne Project Manager ti Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name Important: When filling out A. Facility Information forms on the computer,use Mandolin Hair Salon 7231 only the tab key a. Facility Name b. Facility SIC Code c.DEP Assigned Facility ID to move your 1296 Osgood Street 2nd Floor cursor-do not d.Facility Site Address(Street No.,Street Name,Street Suffix e.g.St,Ave,etc.) e.Secondary Unit(e.g.Building-C,7th Floor) use the return key. North Andover MA 01845 f.City g.State h.Zip Code r� 1296 Osgood Street 2nd I.Facility Mailing Address(If different from the facility site address above) j.Secondary Unit North Andover MA �n k.City I.State m.m.Zip Zip Code 978-697-5380 58-2678675 n.Phone Number o.Fax Number p.Federal Employer Identification Number(FEIN or EIN) A-I. Certification Information Wendy Forgetta Owner 978-697-5380 a.Contact Person First Name b.Contact Person Last Name c.Title d.Telephone Number Wendy Forgetta Owner 978-697-5380 e.Owner First Name f.Owner Last Name g.Title h.Telephone Number I.General business description Wastewater and Holding B. Industrial a g Tank Information Answer all questions, unless you are directed to skip a question. Do not answer questions that you are directed to skip. 1. Major sources of industrial wastewater a. ❑ Process wastewater (Check all that apply) b. ❑ Equipment cleaning wastewater c. ❑ Spent concentrated solution d. ❑ Floor spills or floor drainage e. ® Other(s) (Please describe below) Hair Treatment Describe major sources 2. Major pollutants in the industrial wastewater a. ❑ BOD/COD (Check all that apply) b. ❑ Oil &Grease c. ❑ Low/High pH d. ❑ Cyanide e. ❑ Cadmium f. ❑ Chromium g. ❑ Copper h. ❑ Lead i. ❑ Nickel MAY 2 j. ❑ Silver k. ❑ Zinc I. ® Other(s) (Please describe below) lVu�`d� Hair Color& Perm Products Describe major pollutants Edep01.doc 12/02 Page 1 of 6 i i Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name B. Industrial Wastewater and Holding Tank Information (Cont.) 3. Holding Tank ID (If any): 4. Holding Tank Installation Date: (MM/DD/YYYY) 5. Tank Type(Check one box only): a. ❑ Above-ground b. ® In-ground 6. Tank Construction Material a. ❑ Steel (Check appropriate box(es)or specify): b. ® Concrete c. ® Fiberglass d. ❑ Plastic e. ❑ Other(s)(Please describe below) Fiberglass Primary/Concrete Containment Describe construction material 7. Tank Capacity a. ® Less than 3,000 gallons (Check one box only): b. ❑ 3,000 gallons or more B-I. Compliance Information Section-1 General 101 Do you discharge industrial wastewater to ❑ yes—you must cease discharging and a septic system, leaching field, or complete a Return to Compliance Plan cesspool? ® no 102 Do you discharge industrial wastewater to ❑ yes—you must cease discharging and a storm drain or to the ground without a complete a Return to Compliance Plan surface water or groundwater discharge permit? ® no 103 Is the discharge of your industrial ❑ yes— I have checked with DEP and I am wastewater to a municipal sewer system aware of the restrictions that may apply to feasible? my facility (if your answer is yes to this question, you need to check with DEP for restrictions ® no that may apply to your facility before completing this certification) Edep01.doc 12/02 Page 2 of 6 E Massachusetts Department of Environmental Protection Ll Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name B-I. Compliance Information (Cont.) 104 Is your facility located in the Zone I or ❑ yes— I have checked with DEP and I am Zone A of a drinking water supply area? aware of the restrictions that may apply to (if your answer is yes to this question, you my facility need to check with DEP for restrictions that may apply to your facility before ® no completing this certification) 105 Is this certification for an above-ground ❑ yes holding tank? ® no -skip to question 301 Section-2 Above-Ground Holding Tank 201 Is this above-ground holding tank ❑ yes constructed or lined with material compatible with your industrial ❑ no -submit a Return to Compliance Plan wastewater? 202 Is this above-ground holding tank ❑ yes remotely filled or automatically filled? ❑ no-skip to question 203 202a Have you provided an appropriate ❑ yes audio and light alarm system for this above-ground holding tank? ❑ no-submit a Return to Compliance Plan 203 Have you provided appropriate spill ❑ yes containment for this above-ground holding tank? ❑ no-submit a Return to Compliance Plan 204 Have you provided"Non-Hazardous ❑ yes Industrial Wastewater' labels for this above-ground holding tank? ❑ no-submit a Return to Compliance Plan 205 Was this above-ground holding tank both ❑ yes installed after November 15, 2002 and fabricated on site? ❑ no-skip to question 401 Odep01.doc 12/02 Page 3 of 6 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank Compliance Certification Form (DEP01 ) DEP Assigned Facility lDor Facility Name B-I. Compliance Information (Cont.) 205a Was this above-ground holding ❑ yes —skip to question 401 tank constructed in accordance with engineering plans that were ❑ no—submit a Return to Compliance Plan stamped and signed by a and skip to question 401 Massachusetts Registered Professional Engineer? Section-3 In-Ground Holding Tank 301 Is this in-ground holding tank constructed ® yes or lined with material compatible with your industrial wastewater? ❑ no-submit a Return to Compliance Plan 302 Is the capacity of this in-ground holding ® yes tank greater than 500% of the average daily flow? ❑ no-submit a Return to Compliance Plan 303 Have you provided an appropriate audio ® yes and light alarm system for this in-ground holding tank? ❑ no-submit a Return to Compliance Plan 304 Have you provided"Non-Hazardous ® yes Industrial Wastewater"labels or signs for this in-ground holding tank? ❑ no-submit a Return to Compliance Plan 305 Was this in-ground holding tank installed ❑ yes before November 15, 2002? ® no-skip to question 306 305a Was this in-ground holding tank ❑ yes -skip to question 401 constructed in accordance with engineering plans that were ❑ no stamped and signed by a Massachusetts Registered Professional Engineer? ®depOl.doc 12/02 P606_4 of 6 ■ Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (DEP01 ) Facility Name B-I. Compliance Information (Cont.) 305b Will you (or did you)obtain an ❑ yes - skip to question 401 integrity assessment by November 15, 2003, which will be ❑ no -submit a Return to Compliance Plan prepared by a Massachusetts and skip to question 401 Registered Professional Engineer, for this in-ground holding tank? 306 Was this in-ground holding tank ® yes constructed in accordance with engineering plans that were stamped and ❑ no- submit a Return to Compliance Plan signed by a Massachusetts Registered Professional Engineer? 307 Have you provided an appropriate ® yes secondary containment for this in-ground holding tank? ❑ no - submit a Return to Compliance Plan Section-4 Record Keeping 401 Do you maintain all holding tank ® yes construction and installation records (including all applicable permits)at the ❑ no -submit a Return to Compliance Plan facility? 402 Do you keep and maintain the appropriate ® yes operating records, including wastewater shipment, ultimate destination, and hauler ❑ no-submit a Return to Compliance Plan information at the facility? Mdep01.doc 12/02 Page 5 of 6 • Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or Ll Compliance Certification Form (DEP01 ) Facility Name C. Certification Statement (Note: Complete all required Return to Compliance Plan forms before signing this statement) "I,Wendy Forgetta , attest under the pains and penalties of perjury: (Name of responsible official) (i) that I have personally examined and am familiar with the information contained in this submittal, including any and all documents accompanying this certification statement; (ii) that, based on my inquiry of those individuals responsible for obtaining the information,the information contained in this submittal is to the best of my knowledge, true, accurate, and complete; (iii) that systems to maintain compliance are in place at the facility and will be maintained even if processes or operating procedures are changed; and (iv) that I am fully authorized to make this attestation on behalf of this facility. I am aware that there are significant penalties including, but not limited to, possible fines and imprisonment for willfully submitting false, inaccurate, or incomplete information." Signature Date(MM/DD/YYYY) Wendy Forgetta Owner Printed Name Title Source of Signatory Authority(Check appropriate box): 1. If a Corporation: a. ❑ President b. ❑ Secretary c. ❑ Treasurer d. ❑ Vice President(if authorized by corporate vote) e. ❑ Representative of the above(if authorized by corporate vote and if responsible for overall operation of the facility) 2. If a Partnership: - ❑ General Partner 3. If a Sole Proprietorship: ® Proprietor 4. If an Institution: ❑ Principal Executive Officer 5. If a Municipality or a Public Agency: a. ❑ Principal Executive Officer b. ❑ Ranking Elected Official (Empowered to enter into contracts on behalf of the municipality or public agency) Edepol.doc 12/02 Page 6 of 6 E MERRIMACK ENGINEERING SERVICES, INC. ' PROFESSIONAL ENGINEERS LAND SURVEYORS PLANNERS 66 PARK STREET•ANDOVER,MA 01810•(978)475-3555,373-5721 •FAX(978)475-1448• E-MAIL info@merrimackengineering,com May 23, 2006 Ms. Susan Sawyer: REC `aa?���; Public Health Director 1600 Osgood Street Building 20, Suite 2-36 MAY 2 3 2006 North Andover, MA 01845 TOWN;-,. , ; ; ;-,;a;,;iu0VER HEALTH _'�FAR.TMENT Re: 1296 Osgood Street/Beauty Salon Dear Ms. Sawyer: We are working with Wendy Forgetta regarding the above referenced project. Pursuant to 310 CMR 18.00, permits are not required for installation of an industrial waste holding tank. The current procedure requires the applicant to install a holding tank consistent with the new regulations and then submit a Compliance Certification Form (DEPO1) certifying compliance with DEP regulations. Attached is a copy of this application which will be submitted to DEP upon completion and installation of the holding tank. We hope this information will be helpful in your evaluation of the pending septic approvals. Very truly yours, MERRIMACK ENGINEERING SERVICES W- ^- �--- - William Dufresne Project Manager ti LQMERRIMACK ENGINEERING SERVICES, INC, PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET•ANDOVER,MASSACHUSETTS 01810•TEL(978)475-3555,373-5721 •FAX(978)475-1448•E-MAIL:merreng@aol.com April 20, 2006 Ms. Susan Sawyer Public Health Director APR 2 0 2006 400 Osgood Street North Andover,MA 01845 �� MENT ANDOVER Re: 1292 Osgood St Dear Ms. Sawyer: We have received your review letter dated April 19,2006 regarding the above referenced site. With regard to item#1, we have revised the plan to reflect the location of T-3 &T-4. We respectfully request the North Andover Board of Health approve the use of these test pit results as they are more than 2 years old, and are consistent with recently conducted test pit#5. With respect to item#2 of your letter,we ask that you approve the design as re-submitted, with the condition that a non hazardous industrial waste holding tank permit is filed for and obtained and that no request for a construction permit will be made by our client until this, and all other necessary permits are obtained. Lastly, with regards to item#3 of your letter, since the existing system is only a few years old, and since construction of the existing system required substantial sand fill,we feel it is unnecessary to remove existing suitable sand fill only to be replaced with similar sand fill. Also since both the North Andover Board of Health and the design engineer conduct excavation inspections during the normal course of a system installation,we could collectively agree upon the extent of the sand removal during this inspection as the extent of spoiled soils is typically very evident on systems this new. We appreciate your consideration of this matter and look forward to discussing these issues, and others related to this design at your earliest available meeting agenda. Very truly yours, MERRIMACK ENGINEERING SERVICES William Dufrense Project Manager ti