HomeMy WebLinkAboutMiscellaneous - 404 SALEM STREET 4/30/2018 404 SALEM STREET -�
210/037.6-0050-0000.0
1/
<C�\ Commonwealth of Massachusetts
=U MECity/Town of North Andover
_ - S'ystern Pumping Record
Form 4
wy DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
P � d here. Before using this form, check with your
ea
s that provided he same P "pied to
information must be substantially t in Record must be submitted local Board of Health to determine the form they use.The System Pumping in date in
the local Board of Health or other approving authority within 14 days from the pump g
accordance with 310 CMR 15.351.
A. Facility information
Important:whenion:
(�
1. System Locat
swk:f rV\
filling out forms Y ,
on the computer, v
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover State Zip Code
use the return City(fown
key.
2. System Owner:
a Name
raran
rmo
Address(if different from location)
State Zip Code
City/Town
Telephone Number
B. Pumping Record ' (X�
' 2. Quantity Pumped: Gallons
1. Date of Pumping Date
�Se tic Tank ❑ Tight Tank El Trap
Type of system: ❑ Cesspool(s) P
3. Typ Y
❑ Other(describe):
If. es, was it cleaned? ❑ Yes ❑ No
4. Effluent Tee Filter present? ❑ Yes ❑ No Y
Condition of System:
5. p`n
6. temhhPumped By:
V� C
Vehicle License Number
Name
Stewart's Septic Service �y
Company RECV^'"FED
7. Location where contents were disposed:
Stewa ' -treatment Plant, 20 So. Mill Bradford, Ma 018'.",5 I I
Date
I�TH DEPARTME(yT
ignature of auler --
Date
natur ce g F
System Pumping Record-Page 1
t5form4.doc•03/06
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET_ BOSTON, MA 02108 617-_9 ,"Dp0 OF NORTH AN„Dr~VEH/
BOARD OF 1 EALTH
WILLIAM F.WELD UUL 14 E03
JUDY CORE
Governor Secremn•
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOhFA1tMCommissioner
PART A
CERTIFICATION
Property Address: 404 Salem St.
p � N.Andover, MA Address of Owner:
Date of Inspection: 6/15/98 (if different)
Name of Inspector: James W.. Wright,Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
j Company Name: R.J. Inspections Inc
Mailing Address: 1 Osgood Street, Methuen, MA 01844
Telephone Number: 978 681 -8759
CERTIFICATION STATEMENT
I certify that 1 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-sites sewage disposal systems. The system:
Passes
_ Conditionally Passes
._ s Further Evaluation By the Local Approving Authority
_ ails
Inspectors Signature: Date: (D
The System In44system
u mit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If 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] SYSTEM P
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.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
! One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
j Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiitration, 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.
(reviaad 04/25/97)
Page 1 of 10
DEP on the World Wide Web: http:/Mrww.magneLstate.ma.uddep
Cj Printed on Recgded Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
_.. CERTIFICATION (continued)
Property Address: 404 Salem Street, N.Andover, MA 01844
Owner. Deloras Hayes
Date of Inspection: 6/15/9 8
BJ SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipes) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
. broken pipe(s) are replaced
obstruction is removed
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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and-soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 404 Salem Street, N. Andover, MA
Owner: Deloras Hayes
Date of Inspection: 6/15/9 8
DI SYSTEM FAILS:
You must indicate ei;!;er "Yes" or"No" as to each of the following:
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.
Yes No
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.
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.
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:-
The
ollowing:The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 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:
Yes No
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.
i
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 404 Salem Street, N. Andover, MA
Owner: Deloras Hayes
Date of Inspection: 6/15/98
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes o
Pumping information was provided by the owner, occupant, or Board of Health.
L — None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection./
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site. r
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ,
The size and location of the Soil Absorption System on the site has been determined based on:
_ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [I 5.302(3)(b)]
(revised 04/25/971 Pago 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 404 Salem Street, N.Andover, MA
Owner: Deloras Hayes
Date of Inspection: -6/15/98
FLOW CONDITIONS
RESIDENTIAL:
Design flow: E.p.dJbedroom for S.A.S.
Number of bedrooms: �3
Number of current residents:
Garbage grinder (yes or no):Iy_
Laundry connected to system (yes or no):
Seasonal use (yes or no):_,:�ZC/
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):,ee--'O '
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: ¢allons/day
Grease trap present (tins
s or no)_
Industrial W391'_H'o i Tank present: (yes or no)_
Non-sanitary was arged to the Title 5 system: (yes or no)_
Water meter re i s if available:
Last date of ccupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and-searce of info ation:
System pumped as part of inspection: (yes or no)��C>
If yes, volume pumped: ealions
Reason for pumping:
TYPE OF SYSTEM
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 404 Salem Street, N.Andover, MA
Owner: Deloras Hayes
Date of Inspection: 6/15/98
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _,cast iron 40 PVC other (explain) ,
Distance from private watt► pp or suction line
Diameter
Comments: (condition of joi ting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions:
Sludge depth: xkj
Distance from top ot-sludge to bottom of outlet tee or baffle: ?j-
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffl :_,?a
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in rglation to outlet invert, structural
integrity, evidence of leakage, etc.) 1 �/� A, /�— �C C-2
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of s m p of outlet tee or baffle:
Distance from botto of to bottom of outlet tee or baffle:
Date of last pump' g:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 404 Salem Street, N.Andover, MA
Owner: Deloras Hayes
Date of Inspection: 6/15/98
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
A
Depth below grade:
Material of construction: _concrete _metal _,Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: Iga,lto
Design flow: to d
Alarm level: lar i working order—Yes; _ No
Date of previous pum ng:
Comments.
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: _
Comments:
(note i level and distribu,;an is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
I-i 11
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working ordeVchr
)
Comments:
(note condition of pts pondition of pumps and appurtenances, etc.)
(rwinod 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 404 Salem Street, N. Andover, MA
Owner: Deloras Hayes
Date of Inspection: 6/15/98
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: 3 _
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
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 (cesspo 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 uli ure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Pigs 8 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 404 Salem Street, N.Andover, MA
Owner: Deloras Hayes
Date of Inspection: 6/15/98
i
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Oervation of Site (Abutting property, observation hole, basement sump etc.)
--Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Che -pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
�/ �1��1� /,ice f✓�-� ii 3 jam' n'- -z"
(revised 04/25/97) Page 10 of 10
i
J a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
�- PART C
SYSTEM INFORMATION (continued)
Property Address: 404 Salem Street, N. Andover, MA ,
Owner: Deloras Hayes
Date of Inspection: 6/15/98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house) .
j�NG
r
s
ail
(revised 04/25/97) Page 9 of 10
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.DEP has provided this form for use by local Boards of Health, twn,iPUH1' Ih' Record
be submitted to the local Board of Health or other approving aut or ALTN DEF'Akl iVt i must
A Facility Information
-=,,,yyrian Buns out 1 System Location
wmiputer,use
only .the tab key. Address
to move our ,
cunzor-do not
use the return City/Town State Zip Code
2 System Owner. r
Izm-
Address(If different from.location)
City/rown StatennZip Code,
Telephone Number
Pumping Record
a
A*1' Date of Pumping
Data 2. Quantity Pumped: Gallons
3, :,Type of system ❑ Cesspool(s) [a'Septic Tank ❑ Tight Tank
❑'Other(describe)
Mr,
4 Effluent Tee Filter'present? El Yes to If yes, was it cleaned? El Yes ❑ No
5 Condition of System,°' -
9 Sy em Pumped By
VehicleUcen
$s Number
7-77
her4.Ij'1'47.5,��,`cw �• ::I. ..
{ 7 Mye contents Were disposed:
. Gnu
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71
a t A Signature of Hauler �, � Date
http.//www mass gov%dep/water/approvajs/t5forms,htm#inspect
t5forrn4.doa 08/03 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER OCT -3
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
` (example: left front of house)
DATE OF PUMPING:_� 0 i QUANTITY PUMPEDf�G GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE Ll XEMERGENCY
OBSERVATIONS:
---GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: .'qn0oVef-
COMMENTS:
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- System Pumping Record
Form 4
M
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 tabHug ` I ny
,
key to move your Address
cursor-do not North Andover Ma 01845
use the return
key. City/Town State Zip Code
2. System Owner:
�J Name
ie2m
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record -a- /060
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes V1 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. S stem Pumped By,
E\de(r_jaP .
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
tment Plant, 20 So. Mill Bradford, Ma 01835
S gnature of Haul r Date
Signature of ceiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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C\ Commonwealth of Massachusetts
AM City/Town of
System Pumping Record
Form 4 10 z a�'I
TOWN OF NO TH ANOUlk
DEP has provided this form for use by local Boards of Health. Oth fo M *WA� e
information must be substantially the same as that provided here. 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 1. System Location:
forms on the I
computer,use l
only the tab key Address
to move your North Andover ma 01886
cursor- not
use the return City/Town State Zip Code
key. 2. System Owner'
buw)a
m
Name
�� Address(if different from location)
City/Town state Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ` 2. QuantityPumped.
� , ate I GaMfis
3. Type of system: F1Cesspool(s) ptic Tank El Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
CYI&
6. System Pump
Name I Vehicle License Number
Stewart Septic Service
Company
7. Location where contents were disposed:
S arts Pre treatment Plant 20 So. Mill St, Bradford Ma 01835
Sign auler Date
Signature of Receiving Facility Date
t5form4.doca 03/06 System Pumping Record•Page 1 of 1
I
December 2010
North Andover Board of Health Andover Septic Service
1600 Osgood Street - South Kimball Street
North Andover, MA 01886 RECEIVED Pradford, Ma. 01835
Haulers Permit # JAN 10 2011 h stallers Permit #
BHP-2010-0326 TOWN OF NORTH ANDOvE H P-2010-0422
BHP-2010-0327 HEALTH DEPARTMENT
Date Name & Address GALLON COMMENTS
12/02/lo Levangousky 404 Salem St l000 Good
12/02/10 Hassas 240 Raleigh Taveren Ln 1500 X Solids
12/02/lo Rennie 266 Lacy St 1000 X Solids
12/03/10 Carbenell 1560 Salem St 1000 Good
12/06/10 Shea 105 Sullivan St 1500 LFRB
12/06/lo Banerji 369 Salem St 1000 Good
12/07/10 Menery 66 marion Dr 1500 ,Good
12/08/lo Hamilton 70 Liberty St 1500 Good
12/08/10 Kenny 30 Vest Way 1500 Good
12/09/lo Huges 915 Johnson St 1500 Good
12/lo/lo Reeves 150 Bridge Ln 1500 Good
12/15/10 Karpuski 691 Forest St 1500 Good
12/23/10 Berberian 124 Tucker Farm Rd 1500 Good
11,f�•
"' ECEIVED .
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DE9
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