HomeMy WebLinkAboutPass - Title V Inspection Report - 247B FARNUM STREET 4/29/2024 "Ll Cornmorriv alth of A ass;achusetts
Fills 5 Official Inspection Form
I IXV_
s Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
Owner C Na
wmmtorrratrr is
required for every 6� " m. �` � ' _ o " ' w+
_..
page. C;ityP"town State Zip CodeDate of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered i Y
way. Please see completeness checklist at the end of the form. � � , � � !`
Irapcmrkaurt!t:vwherm
filling out forms A. Inspector Information
on the
only y the tab �r � ( . n 11 &
key to move ysire the
cursor-do not Name' e�f try r
Use the tI return
. .....
Company Naomi
ey �, e
'' �
Urk ' address
cityrfown Male Zip 4„+C1de
AN .
...._._.__. .._... .........._..... ....m...
Telephone Nunitrer Ucense Numbeq
....__....... _....... .. _... .. ............
B. Certification
l certify that: l am a. DEP approved system Inspector in full compliance with Section 15.340 of Title 5
( 10 CMR 15.000); i have personally inspected the sewage disposal system at the property address
listed above„the information reported below is true, accurate and complete as of the time of m
inspection„ and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection l have determined
that the system.
1. % Passes
2, E] Conditionally Passes
. [] Needs Further Evaluation by the Local Approving Authority
. El Fails
r`
w
Cute*
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or L EP)within 30 days of completing this inspection. if the system 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 DER The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address hour the system will perform
in the future under the same or different conditions of use,
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a Commonwealth of Massachusetts
Title 5 Offlocial Inspection Form
.: Subsurface Sewage Disposal System Form- Not for"voluntary,Assessments
r'r perty Address
yy
Owner Ownets Na
information vs
required for ever ✓ "�t ,✓ t .
p Cdty/]Own State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 5.
1) System Passers:
I have not found any information which indicates that any of th, failure criteria described
in 310 C MR 15.303 or in 310 CMR 15.304 exist. ,Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes,
El one or more system components as described in the"Conditional Mess"section need to be
r "* ed or repaired.The system, upon coampletion of the replacement or repair, as approved by
the Bo of health, will pass.
Check the box for "I YMA."no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please expfl°rn,,
The septic tanks is metal and over` years cold*or the septic tanks (whether metal or not)is structurally
unsound,exhibits substantial infwffration"-K xfiltration crr tank failure is imminent.System will pass
inspection if the existing tank is replaced wwi r plying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structural#'�°s und, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old i °°email e.
❑ Y F1 N F-1 ND (Explain below):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Voluntary Assessments
Disposal System �.
Subsurface Sewage p lr Form of o
%f
Property Addrms
tom°
�nI'e . Owner's N �
n
ation is
required for every
Code gate of Inspection
p� wnion
--------------
Ci. Inspection Summary (cont.)
2) System Conditionally lasses (coat.):
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps,/alarms are repaired.
El observation of s '" e backup or break out or high static water level in the distribution box due
to broken or otstructed°p(pe(s)or due to a broken„ settled or uneven distribution box. System will
pass inspection if(with apl"111val of Board of Health)-
El
broken pipe(s) are replaced ] Y M N [] ND(Explain below):
[ obstruction is removed D Y [IN El ND(explain below),-
distribution box is leveled or replaced�, Y El NEI ND(Explain below):
[l The system required pumping more than 4 banes 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 [.. Y [ 1 [ ) ll (explain below):
El obstruction Lion is removed [ Y [-1 N E] ND (Explain below):
"gym
) Further Evaluation is Required by the Board of ti alth:
El Conditions exist which require further evaluation by the rd of Health in order to determines d
the system is failing to protect public health, safety or the er`t ronment.
a. System will pass unless Board of Health determines inauc ordlance with 310 CMR
1 S.3t13(1)(b) that the system is not funncticinirng in a manner wh(bb, will protect public health,
safety and the environment:
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Commonwealth of Massachusetts
Title 5 Wicial Inspection Form
-.. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Pro petty Address
earler Ownees
Y ' scree* _.
re ca srtcorl for cewve r
.informat
,� 1 (
page, C,,ityrFo n State Zip Code Date of rmlwspectbn
C. Inspection Summary (cant.)
Cesspool or privy is within 50 fret of a surface water
ce of or privy is within 50 feet of a bordering vegetated wetland or a salt rnarsh
b. System rrw dl fail unlisis,the Board of Health(anal Public Water Supplier, if any)
determines that the system' rc ioning in a manner that protects the public health,
safety and environment:
L-1 'The system has a septic tank and soil aid Lion system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to
urfrace water supply.
The system has a septic tank and AS and the S is within,a Zone 1 of a public water
supply.
E{ The systems has a septic tank and SAS and the SAS is wwr in 50 feet of a private water
supply well.
[I The system has a septic tank and SAS and the SAS is less than 1.00 feet but 50 feet or
more from a private water supply well".
Method used to determine distance*
""This system passes if the well water analysis„ performed at a DiEP certified laboratory„ for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 511ppr n„ provided that no other failure criteria are triggered, A copy of the analysis must
be attached to this form.
c. Other:
w
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
r3 Backup of sewage into facility or system component due to 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 cragged SAS or cesspool
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" Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
F)roperty Address
owner Ov nor s Name ,
required
information d c .. srarr ? Cores r" *l..
rrmredc4 ra�r everyIty e of Inspection
C. Inspection Summary (cant.)
4) System Failure Criteria Applicable to All Systems: (cam.)
Yes No
El 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 ""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 pipes). Number of times pumped:
E Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of 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 1 of a public water supply
well.
El LS� Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet
from a private water supply well with no acceptable water duality analysis. [This
system passes if the well water analysis, performed at a DEp certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody roust be attached to this form.]
E] The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
dHesign flog of 10,000 gpd to 15,000 gpd.
For large systems,yore must indicate either"yes" or"no"to each of the following, in addition to the
questions in Erection C-.4.- ...,.
Yes No "
the system is within 40 of a surface drinking water supply
" ,
El Ll the system is within 200 feet of a to=sensffiv
surface drinking water supply
the system is located in a nitrogen rea (interim Wellhead Protection
11 ElArea— IWWPA)or a mapped Zone 11 of a public ter scapply well
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� a Commonwealth of Massachusetts
Title 1 5 Official Inspection Form
w Subsurface Sewage'Disposal System Form-Not for Voluntary Assessments
/ ti ,
Property Addrews
< . .
Owner Oymer's Name
mati,on is
infor
required for every Zip Code Date of Inspection
page. Crty/Town ,4a
C. Inspection Summary (corn.)
If you have answered"yes"to any question in Section C:..5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system lies failed.The
owner or operator of any large system considered a significant threat under Section C,.b or failed
under Section CA shall upgrade the system in accordance with 310 C MR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes"or"no"for each of the following for all inspections:
Yes No
Bumping information was provided by the owner,occupant, or hoard of health
E were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period°?
E] have large volumes of water been introduced to the system recently or as part of
this inspection"?
w,Rt?ere as taunt plans of the system obtained and examined? (If they were not
available note as lwl/m )
E] Was the facility or dwelling inspected for signs of sewage back up"?
El Was the site inspected for signs of break out?
El were all system components excluding the SASS, located on site?
EJ Were the septic tank manholes uncovered„opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid„ depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with
. information on the proper maintenance of subsurface sewage disposal systems"?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
[j Existing information. For example, a plan at the Board of health.
o Determined in the field (if any of the failure criteria related to fart C is at issue
approximation of distance is unacceptable)( 10 C;MR 15.3012(5)]
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Commonwealth of Massachusetts
Title 5 OfficialInspection port
SubsurfaceSewage Disposal System Form -Not for Voluntary Assessments
4
PiDparty Addrer;
Owner Own( s htirr� .. � �
information is
required for every c.,r°�� " ."� � C„, 'S 41 �
P City/1 own State ate 4)Code Date of Inspection
D. System Information
1. Residential FlowerConditions:
Number of bedrooms(design): � Number of bedrooms (actual). _
DESIGN flow based on 310 C;MR 15.203(for example: 110 gpd x#of bedrooms):
Description- ..
Number of current residents: .......—_----------.
Does residence have a garbage grinder" ❑ Yes No
Does residence have a water treatment unit' El Yes No
If yes, discharges to:
Is laundry on s separate sewage system?(Include laundry system inspection El Yes No
information in this report:.)
Laundry system inspected? F1 Yes No
Seasonal use? Yes No
Water meter readings„ if available(list 2 years usages(gpd)).' ,
1 .._
Detat"l.
Sump pump? F-1 Yes No
Last date of occupancy: Date;
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Commonwealth of Massachusetts
Title 5 Offincial InspectionForm
Subsurface Sewage Disposal System Form -Not for Voluntary assessments
.. . .
PropertyAddress
�
ata C w+nfo s Name,
WormOw new rara� � �.. �. �.. "�. .....
a'W cityffown state Code Cate of trwstwec tion
D. System Information (cont.)
. Clommerciallindustrial Flow Conditions:
Type refEsf,ablishment.;
Design f�t 1 a5 n 310 t:f t f13): Gallons r day�, � y lei
Basis of design flow(seat 1pwr' sonsi' q t., etc.)-
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? El Yes [_j No
If yes, discharges to, _,....
Industrial waste holding tank present? Yes No
Nara-sanitary waste discharged to the Title 5 system? [l Yes E] No
Water meter readings, if available;
Last date of occupancy/use: _.__._ _.._..._ __...... ....._,
Cfate
Other(describe below):
3. PumpingRecords:
Source of information:
Was system pumped as part of the inspection? Yes [�, No
If yes„ volume pumped: c "
r��ddcam�w
How was quantity pumped determined" � c �
Reason for pumping;
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Commonwealth of Massachusetts
Title 5 Official cial Inspection Form
P� Subsurface Sewage Disposal System Form •Not.for Voluntary Assessments
Property Address
Owrwr rr s Name
information�s
re�quired for every
�k/1 rewnacr��-
�� t�ate�� Zqw � of1 s�retc r��..
age. Y
..... _._. . .... .... _.... ...__....._. ..... ..... ...__...
D. System Information on (cant.)
4. Type of System:
Septic tank,distribution box, soil absorption systern
Single cesspool
EJ Overflow cesspool
El Privy
Rt, Shared system(yes or r`�if yes, attach previous inspection records„ if any)
J lnnovati've/Atterm,ative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
] Tight tank..Attach a copy of the DEP approval.
Other(describe).
Approximate age of all components, date installed(it known)and source of inforrmatiow
Were sewage odors detected when arriving at the site" Yes No
5�w BuuRding Sewer(locate on site plan)*
Depth below grade: )
Material of construction:
cast iron ]40 PVC other(explain): _......._.___. ____... .
Distance from private water supply well or suction line: *
Comments(on condition of joints, venting„evidence of leakage, etc.):
............. _._.....__. .._....._ ._....._.
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. Commonwealth of Massachusetts
T IT
"'He 5 Officloal Inspection Form
Fr Subsurface Sewage Disposal System Form _Not for Voluntary Assessments
Property Address
Owner _
Owner's Name ,� ,
inform
ation N (-».4t' F�C�Yk"a't �� �c1 G�4
�"
required 4r�a every ��"�� Al.
�" a '.. � .,� _
page. Y P ode, Date of In p ctio d
D. System Information (cont.)
6. Septic Tank (locate on.site plan).
Depth below,grade: fees _
Material of construction:
concrete [_ metal fiberglass M polyethylene E] other(explain)
. _...., _ ,. ._.
If tank is metal, list age: _
yea r,,
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) E] Yes E] No
Dimensions: _
Sludge depth: _...w._._w.__ _ ._...__..... . _.....
Distance from top of sludge to bottom of outlet tee or baffle _ . ?. ..._ .. _.__.....___._...
at
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 baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert„ evidence of leakage„ etc.):
/ d rA5Z- .
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Commonwealth of Massachusetts
Title 5 Official Inspection ection Form
Subsurface Sewage Disposal System Farm Not for Voluntary Assessments
Property Address
req�o-wr information
tr r revery � „ % " ' ^",�' `a' .�" .. ) C �. r° P
page, CitY o State 'Z'0'6oxfe Date of talspow.tion
C . System Information (con t.)
T GreaseTrap (locate on site plan).
Depth below grade:
Material of constructicirt:""",
El concrete 0 metal "° , []fiber 1 ss [] polyethylene other(explain);
_-------_
Scum thickness
Distance from top of scum to top of outlet tee or baffle
w
Distance front bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and nutlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tarok (tank must be pumped at time of inspection..)(locate on site plan):
Depth below grade. ''tl - -
Material of construction; Irv'µ ry
EJ concrete E] metal fiberglass [ polyethylene El other(explain):
Dimensions: , ..... _ _........... _ __._. ......
Capacity: '
aitort
Design Flow ✓
galtalils per stay
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Commonwealth monwealth of Massachusetts
Title 5 Official Inspection Form
�w
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Properly Address
arrrr
information is W,
requwed fair every
P" ( 6fyJ Town Statea CodeDate of Icn.s�f:
ector
_.._. ._,, .. . ..._._...__... , _.... . .. ....._. ._.. .........
D. System Information on (coat.)
8. Tight or Holding Tarok (coat.)
Alarm resetn Yes .. No
Alarm level: _.. . Alarm in working order. El Yes E] No
Date of last min
Date
Comments(condition of alarm and float svwltc es,,etc.).
w„
Attach copy of current pumping contract (required), is copy attached? 0 Yes El No
91 Distribution Box (if present must be opened)(locate can site plan):
Depth of liquid level above outlet invert _ :.._ __. _......_......,._.__. _.
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.).
14,
.4
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" Commonwealth of Massachusetts
Till 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for'voluntary Assessments
Prorx" raw,irky r�
Owner
inforation
r uredforlovery 1, _ " , ._ �" _,.. 61 "� �, " c .),.
page, City/Toym State at)Code Date of hspedion
D. System Information (cons.)
10. Pump Chamber(locate on site plan):
Pumps in working order: Yes too*
Alarms in working order: Yes El No*
Comments(note condition of pump chamber„ condition of pumps and appurtenances„ etc..)-.
"
If pumps or alarms are not in working order, system is a conditional pass.
11Soil Absorption System (SAS) (locate on site plan, excavation not required):
If,SAS not located, explain why:
Type:
El leaching pats number:
El leaching chambers number:
leaching galleries number: _..._....._ ... .._._..
leaching trenches number, length y
El leaching fields number, dimensions: --- "~ ~ .-..........
overflow cesspool number„
innovative/alternative system
Type/name of technology:
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......... . ............
Commonwealth of Massachusetts
" Title 5 Official l Inspection Form
"a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
Owner (7mls Name
information is
requirml for every (,`NC �t overt State code of page y Inspection
D. System Information (cons.)
11. Soil Absorption System (SAS)(cant.)
Comments(note condition of sail„ signs of hydraulic failure„ level of ponding„ damp soil, condition of
vegetation„ etc.):
1 . Cesspools (cesspool must be pumped as part of inspection)(locate on site plan).
purnb&, nd configuration
Depth --top of"r"irlu)cl to inlet invert
Depth of solids Dyer
Depth of scum layer *."" ------
Dimensions of cesspool _..___ _..._......_ �__._....
Materials of construction
"
Indication of groundwater inflow n Yes El No
Comments(note condition of soil„ signs of hydraulic failure, level of"ponding,condition of vegetation„
etc.)-. ate"
6h8p,doc-r4N.'MW201 a T do S Offi al lnsp]rt"vcb an Form,Sutmda ce,tiwwagas M^. ne f System•Page 14 W 78
Commonwealth of Massachusetts
Subsurface Sewage Disposal System Foy-Not for Voluntary Assessments
... ..
Property s m „
Owner owrner"s Names
information i - t
regtlirr�rf for every (" {
page. cityrrown State° Zip Code Date of Inspect=
... .. ._,.._.__.. . .,_. - ......
D. System Information (coat.)
13. Privy(locate on site plan):
I eterf is of construction
Dimensions _
Depth of solids
Comments(note condition of soil, s i` of hydraulic failure, level of ponding, condition of vegetation,
etc.): ,
W�
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
..: a
Property Address
Owner Owner's Name , r
information is
required for every
Me- aly/Town Mate zip code Date of WperfOn
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks.Locate all wells within 100 feet, Locate where public water supply enters
the building. Chit one of the boxes below:
D hand-sketch in the area below
Ej drawnng attached separately
of _..
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Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form �..Not for Voluntary Assessments
Owner
Owner's riAr '
rr UeCt�trMr A _'every C�4t Tbt�tnarot� .�. � �... State . ...._.. . � �Code ._..� � ����
page. y to of tnspec�tion
_.._ _.....,.. __. ....
D. System Information (coot.)
15. site Exam-,
El Check Slope
. Surface water ,,,m,:jL,
Check cellar
;shallow walks
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked, date of design plan reviewed: 6ate _ ......._._._.__._._.. w._ ._ . .__...._.. ._._...... ...._------
El Observed site(abutting property/observation hole within 15,0 feet of SAS)
l Checked with local Board of Health_explain:
El Checked with local excavators, installers-(attach documentation)
El Accessed USG USGS database-explain:
must describe how you established the high ground water
elevation:
You Is
Q
e
i ..
Before fining this Inspection Report, please see Report Completeness Checklist on next page.
t5hasp.dm wv,Ir MdA'J18 0.'dWwe 5 MAW hsMA in 6•unt Subsurface uwrsge .Page I 0 18
Commonwealth of Massachusetts
Title 5 UO'Micloal Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ProWty Address
Ouvner
requiredinformatltrrron��every C roer's Narne
urge. City[Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
0 A. Inspector Information. Complete all fields in this section.
14 B. Certification: Signed & Bated and 1, 2, 3„ or 4 checked
C. Inspection Summary:
1, 2, 3,err h completed as appropriate
4 (Failure Criteria)and fa (Checklist)completed
D. Systern Information:
For& Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage leis al System drawn can pg. 16 or attached
For 15, Explanation of estimated depth to high groundwater included
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