HomeMy WebLinkAboutMiscellaneous - 85 SULLIVAN STREET 4/30/2018Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
RECEIVE®
4 11 ;1
1 *12013
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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.
A. Facility Information
1. System Location: Left / Right front of house, Left / Right rear of house, Cght;ec o house eft /
Right side of building, Left / Right front of building, Left / Right rear of building, Under
Address
Cityfrown State
2. System Owner.
Address (if different from location)
Cityfrown
B. Pumping Record
Zip Code
State Zip Code
_ G<kS"-lCs!s
Telephone Number
1. Date of PumpingDat ( Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
6. System Pumped By.-
Neil
y:Neil Bateson
No If yes, was it cleaned? ❑ Yes ❑ No,
Name --
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
0.( UA (--1
F5821
Vehicle License Number
7 - .2
Date
t5fomt4.doc• 06/03 System Pumping Record . Page 1 of 1
5
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:. —O S AUG 3 p 2AA5
TpnIN OG `"`aTu, ?
SYSTEM OWNER & ADDRESS
(example: left front of house)
I -A Z'Uirr -i-1
DATE OF PUMPING:f- 1 3 `o 5 QUANTITY PUMPED l 5o C) GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
EMERGENCY
VI.—
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: 9 -L -S -b
Commonwealth of Massachusetts
assachusetts
System Pumping Record
System OwnerSystem Location
S,
Date of Pumping: � C9 ���� Quantity Pumped: C ��llons
Cesspool: No 141_� Yes [ ] Septic Tank: No [ ] Yes �—
System Pumped by: ea&44W License #
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
2
Commonwealth of Massachusetts
A�-��f,massachusetts
System Pumping Record
Systen'i Owner System Location
Dc,,
i
Date of Pumping: 10-6,?q uafitity Pumped: /96) gallons
Cesspool: No Yes L) Septic Tank: No Yes «�
System Pumped by: Faredoet goanm a License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector
�` C
r. 9
FORM U - LOT RELEASE FORA
INSTRUCTIONS: This form is used to verify that all necessary from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicablAHrOgZiMents.
****************************,APPLICANT FILLS OUT THIS SECat �'°'�'�� **IGJN
APPLICANT �� /J^-1 <(,US -4i
LOCATION: Assessor's Map Number 6�
SUBDIVISION—�—
STREET SSU l/1 U46)
PHONE
PARCEL /
LOT (S)
ST. NUMBER
6
******************* t********************* O I~ F IC 3AL USE
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR
COMMENTS
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED_
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
Revised 9197 jm
DATE
31/1989 15:45 ,FR0:1 Cored t. Donahua. Inc TO Carusso Lau O££ P.02
LOT 2
X07`
Job No. 897038
i'kopos,j ) �6 ,� a8 , Oy�-F- N
"file- Acle! Q,i La
N'P FENAJU
IP
'P
142.6
SULLIVAN RD
This plan was not prepared from an instrument
survey. offsets and distances shown should not
be used to establish property lines.
This pian Is intended for mortgage. purposes
only.
I certify that the structure —shown on this
Plan VI S in conformance with the zoning
setbacks In effect at the time of construction.
I certify that the parcel shown is NCZL
located within a flood hazard area as depicted
on FEMA Flood insurance Rate Maps for
Community No: ---
MORTGAGE LOAN INSPECTION
LOCATION: I 'Jt_ Iii R
nr
SCA E: A'S NOTEP DATE: :1-_3L- E3__
REGISTRY: tul n E SSE
TITLE REFERENCE: : " ' ='
PLAN REFERENCE:
COREY & DONAHUE, INC.
Englnetry & Surveyors
198 Cambridge Roved, WQbnrn. MA 01801
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V
Wreath School
advances in
permit process
By Susan Scully
The town's Zoning Board of
Appeals extended a lukewarm wel-
come to the Wreath School of Mid-
dleton in its fight to locate a_group
home for teens on Sullivan Street.
"The reason this is being done is
because it is state law and we have
no alternative," Zoning Board of
Appeals chairman Frank Serio told
100 audience members present at
the board's Tuesday night, March
14, public hearing. "The only choice
you (the neighbors) have is to go to
your state legislatator and tell him
you do not like this type of law."
With that statement the board, by
a 6-1 vote, approved the right of the
educational school to be occupied
once it satisfies the building codes
set by Building Inspector Robert
Nicetta.
"What we have won is the right to
Continued on Page 23
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North Andover Citizen March 16, IM Page 23
Wreath School advances .. .
Continuad from Page 1
continue our fight," Program
Director Shaun Donahue told the
Citizen after the vote.
"People still believe that this edu-
cational facility is a reform school
or a place students can bring drugs.
It is not true. We are a state funded
(Chapter 766) educational facility
designed to help students deal with
day to day existence," Donahue
added.
One audience members dis-
agreed and stated so before the
affirmative vote.
"I was talking to one of the driv-
ers at the school and she told me
that many of the kids take shots and
sometimes the school runs out of
shots and the kids get violent. I do
not want that in my neighborhood.
This is a reform school and I do not
want to live next to it. Why doesn't
he build this school, next to his
house?," Walter Hoyt, Sullivan
Street said.
After doing some independent re-
search board member Alfred
Frizelle, Appleton Street, decided
to vote in favor of the school that
provides education to learning dis-
abled and special needs students.
"There are not going to be any-
more drug dealers or juvenile delin-
quents in this facility than there are
already in town. We are not bring-
ing in Walpole (state prison). But,
all this discussion is irrelevant.
Like it or not, the law says we can
not regulate this educational facil-
ity," Frizelle said.
The Wreath School, based in Mid-
dleton, will now submit parking
plans, a sewer and septic study and
any additional information re-
quired by the building inspector to
receive its actual occupany certifi-
cate for a maximum 12 males and
two full-time 24 an hour coordi-
nator -supervisors.
"What this vote means, is that the
school cannot not be denied a cer-
tificate because the neighborhood
does not like it. We like everyone
else have to follow state and town
building codes. If we follow all the
codes required for any one else in
that residential area, we should be.
issued the cerificate," David Kole -
man, Salem, legal counsel for the
Wreath School said.
. 4
VISI
Thep
Histoi
sachusl
day thr
5 p.m. j
from 1
Thef
adults'
childr'
are ai
On i
on tY
cesT
.,_g,h
1110
s, .
z 2 5T
"le—
b6
_Vol �t
AG TO
Zoning board should�,.cjua,?
approve group- home
That a group of emotionally and learning disabled teens
can be branded criminals sight unseen is surprising.
That race is a component reet is truly disturbing rotest over a proposed
group home on Sullivan
The Wreath School in Middleton has advanced a rather
modest proposal to install nine youths in a larger vacant
home off Turnpike Street. These kids are part of a residential
program the special needs school offers. Just like its college
preparatory counterpart over on Great Pond Road, the
Wreath School offers families the option of boarding their f
students away from home. The school emphasizes the learn-
ing of social skills in a homey environment.
Tuesday, the Zoning Board of Appeals should grant the
school a variance to allow the group home in a residential -2
district. Building Inspector Robert Nicetta has not issued a
permit on the grounds our town does not have regulations
this type of home.
We do agree with some neighbors that the house doesn't
offer a good play area. But there are many youngsters who
do not have that amenity outside their homes. Our town has a
reasonable park network, and the school itself has playing
fields.
In the absence of zoning, we urge the Board of Appeals to i
embrace this alternative type of housing.. This is a case
where changes in our society have moved faster than zoning
regulations.
North Andover..
Wreath School plans
OK'd by Zoning Board
Despite strong objections from
neighborhood residents, the N eth
ats
fAndover Zoning Board of APp`
approved the Wreath School's Plansi
to renovate a Sullivan Street house;
for use as a residence for nine to
oITl
emotionally disturbed boy
s. loo Boston Hill area residents came
to the meeting ng to tell of their fears of
violence, vandalism and
failing
Board
property values, but App
Chairman Frank Serio said the ap-
plicants had fulfilled all the re-
quirements of the law, leaving the '
board no alternative but to approve
the permit. The Wreath School
currently operates a program
Mid-
dleton for 38 boys with emotional
and learning problems. Middleton
Police o Peachy
re
ported no Chief
!�•
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BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
TEL: 682-6483
Ext. 32 or 33
3 - r- -k'
Nie Gt�G --c �-62wIe na'S-GS �'
BOARD OF HEALTH
Building Inspector
Re: lot 3 Sullivan St.
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
TEL: 682-6483
Ext. 32 or 33
2-14-89
There is a proposal to house almost twenty people at this
house. Here are some points to consider.in determining the
maximum level of occupancy of an existing building:
Water. The well yielded 1.5 gallons of water per minute after
a four hour pumpdown. This appears to be enough water to supply
at least twenty people. ( There is no standard for a minimum
quantity that we could find, this calculation is based on the
estimated maximum sewage flow. )
Sewage. The existing septic system is not large enough for
this proposal but it could easily be added onto, all it needs
is extra leaching area which could be supplied with another
trench. The septic tank is large enough.
Space. Each room occupied for sleeping purposes shall contain
at least 70 square feet of floor area for the first occupant
and 50 square feet for each additional occupant.
Sincerely,
Michael Gra
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-9- aged
OF NORYN 4
e '1'
OFFICES OF: o'om Town of
* a
APPEALS NORTH ANDOVER
BUILDING
CONSERVATION 9seq°" 5E`4 DIVISION OF
HEALTH
PLANNING PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON, DIRECTOR
MEMO TO: MICHAEL GRAF, HEALTH SANITARIAN
FROM: ROBERT NICETTA, BLDG. INSPECTOR DefiY
DATE: FEBRUARY 10, 1989
RE: SEPTIC SYSTEM, LOT 3 SULLIVAN ST.
120 Main Street
North Andover
Massachusetts 01845
(508) 682-6483
Is the septic system on Lot #3, Sullivan Street capable of
handling approximately 20 people?
Also, what is GPM of water supplied from the driven water
well?
Please respond in writing prior to February 14, 1989 as this
information is needed for the Zoning Board of Appeals meet-
ing.
Thanks for your cooperation.
DRN:gb
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G�.�--� C i � � w . l
89 East Street, Middleton, Massachusetts 0194919
Jo^,
Tel phone: (617) 774-3294
Permit #
BOARD'OF HEALTH
Town p f North'Andover;Mass.
Date August 2719 86
.APPLICATION FOR WELL & PUMP PERMIT
Application is hereby made for permit.to drill a well (x-3). Application is
made to install (_) a pump system-.
Sullivan Street North Andover, # 3
Location: Address > Mass. ..Lot
Owner Walter Johnson
Address 64 Linebrook Road, ,Ipswich, '•
Well Contractor C.M.RollinsCo., Inc. Address129 Depot Road, Boxford,Mass. Te1887_2320-
Pump Contractor. Address Tel. -
WELL CONTRACTOR (To be completed at time of pump test)
Type of Well Drilled Well used for Domestic
Diameter of Well
Depth of Bed Rock
a
10'
Was Seal Tested? Yes ( ) No ( )
De-pth of Llel1 530'
Depth to Water -
Size of. Casing 611.
r
Depth casing into Bed Rock -26'
Date of Testing
Well Ended in W.h-a-t- Material Rock
3 # 6 " Delivers 12 Gals.Per Min. for 4 hours
Drawdown feet after pumping hours -at GPM
Date of Completion 8_2'5-86
ignature Wel ntractor
PUMP INSTALLER (To be-- f-i11'ed in- before installation)
Size & Name Pump ___Pump Type Used
Water Pump Delivers GPM " Size of Tank
Pipe Material Used in Well: Cast Iron (_) G*a]..vanized (_) Plastic
Well Pit ( ) or Pitless.Adapter
Was sleeve used to protect pipe? Yes (_).NO(_) Type or Name Well Seal
14
Date
�'r�r�M�r�t�kti4�lr��eSk►4�Mti'e�VrS4tiatihs4ti�tiMi4�r�k�lr�t�rdrs�r�rslrti4�r�lr�,ti�C5�51ri�►'r5�t�cti4�'c;'�:'S'�?�ic'GU��;P',I:?�c D��� ��Ftk*kr#�s�rs�t�r
Date Water analysi-s repor-t submitted to Board of Health
Date release given to owner of record & Bldg. Insp
Health Inspector
a
6
�
l
I
T a
Biornarine
esearch Corporation
P. O. BOX 1153,16 E. MAIN ST., GLOUCESTER, MASS. 01930•TELEPHONE: (617)283-7705
fit
wertif trate of Analysis
To: Mr. Walter Johnson
64 Linebrook Road
Ipswich, MA 01938
Attn:
Re: Well Water Analysis
Sample No.: 15493
Report No.: 14242
Date: 9/9/86
Sample Description: Sample of water taken from a new well, 500 feet deep, located
on Lot #3 Sullivan Road, North Andover, Mass.
Sampled By: Delivered by customer. Dates August 27, 1986
Findings:
pHValue ........................... 7.74
Hardness (as CaCA, mg/L)......... 84
Iron Content (mg/L�... .. <0.02
Manganese Content ( L) .. 0.32
Sodium Content (mg/LL............... 5.02
Nitrate Nitrogen Content (mg/L)..... 0.05
Specific Conductance (umhos/cm)..... 275
Remarks: The manganese content found in this water exceeds the EPA recommended
level set to prevent nuisance staining.
Inspection of pH, hardness and specific conductance does not indicate a potential
corrosive problem.
cc: Mr. Michael Graf
North Andover Board of Health
By:
Jofin Marletta
Laboratory Director
Biomarine Research Corp.
I f
BOARD OF HEALTH
No.Andover, Mass.
}
APPROVED - DATE
Provided:
SUBSURFACE DISPOSAL DESIGN CHECK )' [sT
DISAPPROVED
Reasons:
LOT #
DATE
Title V
Reg 2.5
-- ---
Reg 6
Reg 10.2
Reg 10.1
FAIL
CK
The submitted plan must show as a minimum:
A) the lot to be served -area dimensions lot # abutters
b location and log deep observation hoes -distance to ties
c location and results percolation tests -distance to ties
d design calculations & calculations showing required leaching area
(e) location and dimensions of system -including reserve area
f) existing and proposed contours
(g) location any wet areas w9 thin 1001 of i ewa-ge disposal system or
disclaimer -check wetlands mapping
(h) surface and subsurface drains within U31 of sewage disposal
system or disclaimer ,
(i) location any drainage easements within 1001 of sewage disposal
system or disclaimer -Planning Board fi'�s
(j) known sources of water supply within 2C )I of sewage disposal d
system or disclaimer
(k) location of any. proposed well to sr- re 'ot-100, from leaching facility
(1) location of water lines on property -101 '-om leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals '
(p) no PVC to be used in construction
(q) profile of system -.elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Otter elevations
(r) maximum ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Septic Tanks
(a) capac t es- 50% of flow, water table, tees,,, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground swimmi g pool
(d) 251 from subsurface drains
Distribution Boxes
�e greater 0.08 „,_
1(b)
140. 5_9,
1 -07 -
FF r � � 3 k, °-.
0 0 dL
�OC4-fOJO
00
14)
T--3
40
zg.?9-
SITE PLAN
401
i0 -
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
Ihereby m e application for a permit for a sewage disposal installation at
I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1/ until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of /a in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of f F 45 lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE ?' -' -)
I have inspected the uncovered system indicated above and find everything done
as described.
DATE Z0_ 1 1-71
Signature of ns sting Officer_
Percolation Tes" �,Ulltc
Garbage Grinder ,
G -
Signature
of
scant
I hereby issue the
above permit for the Board of Health of
the
Town of North
Andover, Massachusetts.
DATE - % 7 -7/
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE Z0_ 1 1-71
Signature of ns sting Officer_
Percolation Tes" �,Ulltc
Garbage Grinder ,
I IL
X69
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
1
130
I �. 3 r
/000 &
'ISE 0-t-
1. NAME/ DATE — /� V
2. ADDRESS / 6 -1�LOT NO. r2 TEL.
3. NO. OF BEDROOMS DEN YES NO
4. GARBAGE GRINDER YES NO !/
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. /1" N
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE No K E
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE 3,42/21
NAME OF APPLICANT Walter Hoyt
LOCATION Lot #2 Sul,jiya Street
Address of lot no.
BUILDING: Dwelling X Other
SYSTEM: New X Repair
GENERAL.DESCRIPTION OF LAND high
SUBSOIL: Clay Gravel Sandy Qjgy X -
PERCOLATION TEST 3 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK.1.000 gallon capacity.
LEACH FIELD 80 lineal feet of drain pipe.
) A)fi" _1 t';.'tz
10�illiam J. D coli, Engineer-,
Board of Heal
TOWN OFK%�jW-cf,
,
SYSTEM PUMPING RECORD
s
DATE: 1-0- tip{-1�
SYSTEM OWNER & ADDRESS
�0
'�[ I
SYSTEM LOCATION
(example: left front of house)
kokkSlf—
DATEOF'PUMPING: _ 4 QUANTITY PUMPED: 0-6 GALLONS
CESSPOOL: NO YES EPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE Z- EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
•1 3IuIB►If _
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
Townof North. And«:aver, MA
Watershed Septic System
Servicing RepDrt
Date : ` -2-& - 94
Homeownefs! Street
Phone IO ac �- -%,!:�,, S
Nature of Service:
I
1 Observations:
4
i
1 �
ascription of Work:
Routine
Emergency
Good Condition
Pumpi.ir
Addri.!ss : /
Phone
Full to Cover
Baffles in Place
Leachfield Runback _
Excessive Solids
Heavy Grease
Roots
Other (Explain)
i
'qents:
I
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;a
m
mQllvvQ!;�dt h f
A I'M ve
4 rd RECEIVED
JAN 15 2008
B04 Saar O'l HQ-alth, Tha
rd of Faalth car
ritY- HEALTH ONA
rMaTion
2�
Aq
; rrofn
Date
T
4, EffjUOnt,j-&e
flump�4 ay,
ROOTF-�MAN
12 EAST DRACUT RQAl)
WTHUEN, MA ()1844
contents V,,C�re dlsposarj:
ll,$/l YOFMq.
Tank
Ll TjQl)t T�wjlc
ye$ 0 'No
V-q—hOla
3
ommonwealth of Massachusetts
City/Town of Ivo" #Pdojo1
System Pumping Record
Facility Information:
System Location:
Sullrua0 5�-
AUG 10 2010
TOWN ®' NpRTW,4N�6V
HEA�7W nem. o-- -- eR
Address
vo
City/Town State Zip Code
System Owner:
V e
Na
Na. me
Adress (if different from location of pump)
City; Town
State Zip Code
-(o vs — -7/5-S
-
Telephone Number
Pumping Record -
Date of Pumping / �/ % U Quantity Pumped / ¢ S^� gallons
Type of System Septic Tank Grease Trap Other (what)
System Pumped by: ��j( L�
Company: ROOTER -MAN 46 Portland Street Lawrence, NLA 01843
Location where contents were disposed:
4 Lao
Signature of Hauler I //U Date