HomeMy WebLinkAboutMiscellaneous - 759 DALE STREET 10/29/2015 Town of North Andover, Massachusetts Form No. 1
r1ORTH BOARD OF HEALTH
OF Si�eo bq4,
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�Qp .. Pppy��* APPLICATION FOR SITE TESTING/INSPECTION
�SSACHUS��
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee Test No.
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
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Town of North Andover, Massachusetts Form No,z F
f NORTH BOARD OF HEALTH
O
0 30
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DESIGN APPROVAL FOR
ass"""SEt� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
r.
Applicant Test No. �.
Site Location_ U-)—F L�
Reference Plans and Specs. j1-
—ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed t.
in accordance with regulations of Board of Health. r
CHAIRMAN,BOARD OF HEALTH
V
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Fee Site System Permit No. r
" Tow of North
of Oo*H1 n Andover Massachuse tts
..;a.a"o
Form
BOARD OF HEALTH N0.3
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' SSACHUSEt� DISPOSAL
WORKS CONSTRUCTION PERMIT
Applicant � d1
NAME
Site Location Lc T- ADDRESS
t-� TELEPHONE
Permission is hereb
: Sewa y granted to Co
ge Disposal System as Shown on the pt ( or Repair
an Individual Soil Absor ption
. eslgn Approval S.S. No,
J� CHAI RMAN,
Fee S , BoARo
OF HEALTH
D.W.C. No. �—�=
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(a) The retaining wall shall be constructed of reinforced concrete, shall have no
and shall be waterproof,
�a (b) The retaining wall shall be designed by a Registered Professional Engineer,
"X
certify that the above condition is met by the submitted design.
(c) The upgradient side of the retaining wall shall be waterproofed.
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" (d) Construction of the retaining wall shall be supervised by the design engineer. "{
(e) An as plan shall be prepared and certified by the design engineer that the
� � been constructed in accordance with his approved design plan.
y L" (f) The elevation of the top of the retaining wall shall be no lower than the "brealtou�%
' elevation,which is the elevation of the top of the two inch layer of�/e inch to '/2 inch
u
washed�F
stone aggregate cover, p
(pJ The distance from the wall to the edge of the leaching area should be at least ten feet^ " w
(3) FM material for systems constructed in fill shall consist of select on-site or imported soil
material. The fill shall be comprised of clean granular sand, free from organic matter and
deleterious substances. Mixtures and layers of different classes of soil shall not be used. The ti
fill shall not contain any material larger than two inches. A sieve analysis,using a 44 sieve,shall M �c
be performed on a representative sample of the fill.Up to 45%by weight of the fill sample may y�
be retained on the#4 sieve. Sieve analyses also shall be performed on the fraction of the fill
sample passing the#4 sieve,such analyses must demonstrate that the material meets each of the
following specifications:
SIEVE SIZE EFFECTIVE %THAT MUST
PARTICLE SIZE PASS SIEVE
# 4 4.75 mm 100%
450 0.30 mm 10%_ 100%
#100 0.15 mm 0%_ 20%
4200 0.075 mm 0%_ 5%
A plot of the sieve analyses of the portion of the sample passing the 94 sieve shall fall on or
between the Iines.on the following graph:
PARTICLE SIZE DISTRIBUTION
100 #200 f100 f50 A�, G Ab �ti,�P �D e'
S „�evc Size
I 4r'
so
• I I 1 I I�� � � /� I I I
70
W 5q
z W 40
30
20
10
0 LL L�,
Micron 60 200 600 2 6 10 MM
12/1/95 (Effective 11/3/95)-corrected 310 CIva-531
PLAN REVIEW CHECKLIST
ADDRESS ENGINEER
GENERAL
3 COPIES STAMP
...... LOCUS NORTH ARROW SCALE
CONTOURS PROFILE SECTION BENCHMARKL ----- SOIL &
PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS
WATERSHED?41,1�- DRIVEWAY_(Elev) WATER LINE FDN DRAIN,,""
SCH40 L,,' TESTS CURRENT?— SOIL EVAL
SEPTIC TANK
MIN 1500G . 17 INVERT DROP GARB. GRINDER / (+200% EDF)
251 TO CELLAR MANHOLE1� ELEV GW # COMPS .
D-BOX
SIZE # LINES
FIRST 2 - LEVEL STATEMENT
INLET/0, OUTLET M -, 17 (2 11 OR . 17 FT) TEE REQ D?.
/6,J, 7 17
LEACHING
MIN 660 GPD? AREA FROM PRIMARY? 2% SLOPE
RESERVE AR
100 ' TO WETLANDS 100 - TO WELL S 41 TO S .H. GW
351 TO FND & INTRCPTR DRAINS 6" 3251 TO SURFACE H2O SUPP '
41 PERM. SOIL BELOW FACILITY,"` MIN 1211 COVER FILL?_ (251
if above natural elev; 101if below) BREAKOUT MET?
TRENCHES
MIN 660 gpd,� SLOPE (min . 005 or 6"/100 ' ) t,,,"""" SIDEWALL DIST. 3X EFF.
WORD (MIN 61 ) RESERVE BETWEEN TRENCHESZ, IN FILL? C--- MUST
BE 101 MIN. 4" PEA STONE? VENT? (>31 COVER; LINES >501 )
BOT 7 + SIDE
X LDNG TOT
(L x W x #) (DxLx2x#) (G/ft2)
Copyright(0 1995 by S.L.
Starr
,DAJ'E. 'N"T " I Lfl 'R'S
/W2
LOCAT[o �
1,ICE NS ED E`,1STAJ-'-LE1 R:
TELEPRO
N.EVV CONSTRUCT[ON:
'I i FOU'NDATIOLN AS--BfjfL'r.
'[FNT-W PLEASF- ATTACI
Administrative Use Only
$75.00 Fee Attadied? Yes-
Foundation As-Built? Yes
Approval Date:,/Z
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************A/pppl`ic/a/nt/y fills out this section***************/*c***2
APPLICANT: _ /y%/7��y ( � Phone ��4 e_?/5z
�r
LOCATION: Assessor' s Map Number �D�I G Parcel
Subdivis ion iS/Orfl� Lot(s)
Street ��T _Z n � L� s� St. Number
************************Official Use Only************************
RECOMMENDATION OF /AGENTS:
Date Approved
Conservatioft Administrator Date Rejected
Comments
Date Approved 1
Tow i P a3�n Date Rejected
Comments
Date Approved
Food Inspector-Health Date Rejected
Date Approved
Septic Inspector-Health Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit l
Fire Department
=
Received by Building Inspector Date
66 LIMETAN ROAD Wt$
�FORb, MA OI986 t54H) 692-83 P
1 � FAX X609 692-0023 1.64O.649•TE$T
N f
urr
Report .
!� N Aber r C��my-17437 Report Uate z October 17, 1995
Client c sample Taken ,fits
E.M. Young Artesian well Lot D 041e Stj " °'.
36 Pelham Rd.
N,Andover#Mr�s>�.
Salem NH 03079 Lod. 31
sample Taken gy: im Young staff Oni october 1�, 1995
1 '
CERTUICATE Or ANALY610 j
TEST PARAMETEltt EPA max RZBULfis vcax'rs
Total Coli form -(p) A 0 Per 100m7
t
iron (0) 013 0.06 M9/4
1
Manganese (s) 0605 0.01 1 mg/L
sodium 20 0.1 mg/L
chloride (s) 250 52.7 mg/T,
Hardness Np Zimit 148 m9114
i
Nitrates(as N) (P) 10. 1.1 + mg/4
� 1
Nitritoo(as N)
pH (a) 6.5-8.5 7.1 sU
NT-Not Tested, #"Value Exceeds EPA $TO, TNTC®Too NU�erous tO Count
*-Baekground Bactgria Noted, "-EPA Advisory Limit j
,mZkoeeda EPA Adv�80ry Limit j
(P)-Primary ZrA S 'andard, (6)¢Secondary EPA standar (may affect
aesthetioG of dri king water i.e. taste, color, etc l)
1
This water samp�e,!. as submitted, meetp or exceeds E health standards
for the paa:am4taro listed above. The t�uality of thi water is
accepted as POM¢BIE according to EPA Ataodards. �
Massaahtlsatts State Certified M aha� A. Ca �loon, for
Testing Laboratory #MAgyB ThvratensenL boratOry iris. i
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"90 "9�r TOWN OF NORT14 ANDO'vt'p,' ,xwa OA .m. ALT
BRD OF• w 7p
3
.••"fi BOARD OF HEALTH
�ssACHUSE� NORTH ANDOVER, MASS.
APPLICATION FOR WELL AND PUMP PERMIT
Permit #V G
jo ��j�"� v Date o 3
A permit is requested to: drill a well X install a pump l<
LOCATION° 401 0 /0/9/c Lot #
Owner n'"�1on 0/ 010 Address ,S"y� Tel !c
Well contrctr 't" M yogw6p Add. 36 1e1W,1w, 1?9 _Tel
C4 le r1i
Pump Contrctr s"r�m Add. Tel
WELLS (To be completed at time of pump test. )
Type of well O/t;//e v Use fJ® rn�"s`1I"G
Diameter of well �v" Size of casing
Depth of bed rock �'� Depth casing into bedrock
Seal been tested? Yes ( 1�) No (�) Date of test
•c'c U ,�
Depth of well '330 Water-bearing rock
Depth to water /'v � Delivers f8 GPM for
(how long?)
Drawdown 106'6' feet after pumping 141 hours at /F GPM
Date of completion_
Signature o ell ntractor
PUMPS (To be filled in before installation. )
Name & size of pump }r'j 4-7/4 f le- y O 0 0 SS Type s. k kS
Size of tank " Pump delivers GPM
Pipe used in well: Cast iron (_) Galvanized (_) Plastic ( L=�
Sleeve used to protect pipe? Yes (_) No ( L_ Type well seal
Date/o ��-
Signat re 6f pump installer
Date water analysis report submitted to Board of Health
Plumbing inspector Wiring inspector
Board of Health j
I
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Department of Environmental Mar gem it/D'v 4i n, f W atvvFfesou�ces
n �.,
WELL COMPLETI N R PORT
WELL LOCATION "GRAPHIC DESCRIPTIO
Address o L7 AP /d r/-C. .fur /
✓� C S/, � ,.n, N S W of
(feet) (circle)
City/Town /y)r^i rW /47 M 4 Sd 6 ell f /44V '?
Well owner /7 r/-/4 rl f 0;0 (road)
Address S"z/? t/irrrP J i N) E W of
/t�6 y7/G/ 14/1-71 a � .9rr lnrl,in tenths! (circle)
r"'�..i intersect. w/ l IAV
Board of Health permit obtained: yes no ❑ (road)
WELL USVP.bl!cE] WELL DATA
Domestic Industrial ❑ Total well depth �t ft.
Monitoring❑ Other Depth to bedrock ft.
/n Water-bearing rock/ttnconsolidated material:
Method drilled V _
Date drilled /® 13 Description �c/`�"�' ✓rec {
CASING
Water-bearing zones: r�
. �
Type
'S" 1) From ( J To
Length 0?Q ft. bia(.L 2) From—To
l in. 3) From To
Length into bedrock— ft.
Gravel pack well: dia.
Protective well seal:
. Screen: dia.
Grout_ Other Slot'` length from_to
STATIC WATER LEVEL(all wells)
Static water level below land surface I& � ft. Date
WELL TEST(production wells)
Drawdown/'b V ft. after pumping /11/ fir, min.at gpin
How measured "p Me Recovery Q ft, after_hr, min.
0
LOG of FORMATIONS COMMENTS
Materials From Ta
u a: ,/ Driller t � �;/6 41.r
,rrr�r> 71'Z 1- 3 ji Firm y d'ga C .4,r%rfi.�n Grr-!C
Address
'i
City/Town �I/C1/r,�i / 1t✓
Supervising Driller Reg.#
sox
Sr nature o/rapervisln registere well driller
Preeaa print firmly BOARD OF HEALTH COPY
I
-- --- ------- -- '- ---' —
NUMBER FEE
THE COMMONWEALTH OF MASSACHUSETTS A-25-00
NAME
ADDRESS
IS HEREBY GRANTED A LICENSE
Well Permit — Lot D Dale Street
This license is granted in conformity with the Statutes and ordinances relating thereto, and
`
i
f
Andover Town of North �� l
Q� gURA ig�4'� I
OFFICE 01,
COMMUNITY ITY DEV L,C "i' AND SERVICES
i
146 Main Street `6(pa reo^vP`y q`wJ
KENNETH R.MALLOW North Andover, Massachusetts 01845 Sacwus��
Director (508) 688-9533
August 21, 1995
Scott Giles
50 Deer Meadow Road
North Andover, MA 01845
I
Re: Lot "D" Dale Street
Dear Scott:
This is to inform you that the proposed plans for the site
referenced above have been disapproved for the following reasons:
1) Depth of trenches do not coincide on profile and
section.
2) Trench lines must be connected to vents if over 50
feet in length. (310 CMR 15. 251 (11) and 15. 241
(a) -(f) • )
3) Note three concerning fill material shall read:
"Fill material shall comply with 310 CMR 15. 255.
4) Please note top of stone is at 104 .96.
5) Septic tank must have a manhole to grade.
If you have any questions, please do not hesitate to call the
Board of Health Office at the number above.
Sincerely,
3
Sandra Starr, R.S.
Health Administrator
SS/cjp
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEt IATI 688-9540 PLANNING 688-9535
Julie Parrino A.Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell
Town of North Andover o" NORTH
-°
. OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES °
146 Main Street �, •,,,D- °�h
KENNETH R.MAHONY North Andover, Massachusetts 01845 9SSACHUS��
Director (508) 688-9533
August 21, 1995
Scott Giles
50 Deer Meadow Road
North Andover, MA 01845
Re: Lot "D" Dale Street
Dear Scott:
This is to inform you that the proposed plans for the site
referenced above have been disapproved for the following reasons:
1) Depth of trenches do not coincide on profile and
section.
2) Trench lines must be connected to vents if over 50
feet in length. (310 CMR 15 . 251 (11) and 15. 241
(a) -(f) . )
3) Note three concerning fill material shall read:
"Fill material shall comply with 310 CMR 15. 255.
4) Please note top of stone is at 104 . 96.
5) Septic tank must have a manhole to grade.
If you have any questions, please do not hesitate to call the
Board of Health Office at the number above.
Sincerely,
Sandra Starr, R.S.
Health Administrator
SS/cjp
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Julie Parrino D.Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell
NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
FEE PERMIT # w DATE RECEIVED
APPLICANT MAP PARCEL
ADDRESS LOT T>
ENG. '_ma ..
ST. J-)!A) - -1,57
ADD.
PLAN DATE REV. DATE
CONDITIONS OF APPROVAL
APPROVED DISAPPROVED
REASONS FOR DISAPPROVAL:
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Commonwealth of Massachusetts
v-1 - , Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By: .....
Witnessed By:
.... ... .... ......... .. ....... ._ _
Location Address or /��G: �JX,�6 � Owner's Name, �-.�Q/-/l� ���"'I�Tf �� , /Ul��'�j-/�(y,7
Lot p Address.and �' / j" � '} �L_�g��� I�O 1� 5,J-
Telephone d
New construction ❑`J Repair ❑
Office Review
Published Soil Survey Available: No ❑ Yes
Year Published /`%�L Publication Scale / �?� '' ' Soil Map Unit
Drainage Class Soil Limitations ......
Surficial Geologic Report Available: No El—" Yes ❑
Year Published Publication Scale
Geologic Material (Map Unit) _ _ __ _.... .. .. _...
Landform
Flood Insurance Rate Map: ot'Vk` 06 6) 7 G.
Above 500 year flood boundary No ❑ Yes .
Within 500 year flood boundary No ❑r Yes ' ❑
Within 100 year flood boundary No ❑' Yes ❑
Wetland Area:
National Wetland Inventory Map (map unit) ................. . __ ._..... ........ . ... ..............................
Wetlands Conservancy Program Map (map unit) _............ .... .. .. .............................
Current Water Resource Conditions (USGS): Month 1: C5y
Range : Above Normal ❑ Normal ❑" Below Normal ❑
Other References Reviewed:
On-site Review
V,
Deep Hole Number _ J Date: '5JJ` Time: Weather 0JUN
Location (identify on site plan)
Land Use C000))✓. Slope (°io) Surface Stones 4)_:
Vegetation
Landform
Position on landscape (sketch on the back) _._ __.......
Distances from:
Open Water Body _ feet Drainage way _ _ feet
Possible Wet Area 166 feet Property Line ___ feet
Drinking Water Well feet Other
DEEP i
OBSERVATION HOLIE LOG
Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other
(Inches) (USDA) (Munselll (Structure, Stones, Boulders,
Consistency. % Gravel)
n
1-3; _;,3,1r' ;tips <> c
/ s
%) %)
70 316
f
gi (%� /1��� _ . Depth to Bedrock:
Parent Material (geologic) ��/ L _.._. ._ _........0.......
Depth to Groundwater: Standing Water in the Hole: `/ / Weeping from Pit Face:
Estimated Seasonal High Ground Water: 3� :,
On-site Review
Deep Hole Number Date: f/ '/`i Time: ' } Weather
Location (identify on site plan)
Land Use Z-4 N 16 Slope (0/6) _ Surface Stones
Vegetation ..... _
Landform
Position on landscape (sketch on the back) ......_ _.. .....
Distances from:
Open Water Body _. __. feet Drainage way feet
Possible Wet Area '!"C' feet Property Line _ __. feet
Drinking Water Well _ feet Other
It
DEEP OBSERVATION HOLE LOG
Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other
(Inches) (USDA) (Munsell) (Structure, Stones, Boulders,
Consistency. %' Gravel!
GLJ /,)lC Ca
"7
�q 6 1�/V)/ 'tC>Gc17
<3
Parent Material (geologic) _.. _ .. Depth to Bedrock: .......... .
Depth to Groundwater: Standing Water in the Hole: 4 ... ... Weeping from Pit Face:
Estimated Seasonal High Ground Water: c 3�
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EHEALTH Commonwealth of Masachuset
= City/Town of ()1
�/Stet11 Ut11p1rt Record ANDD10aH
T N'1`
Form 4
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 4Ei frqntpj,ho Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityrrown State ip Ged'e
Telephone Number
B. Pumping Record .
1. Date of Pumping 'Y 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
i c�
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' re contents were disposed:
G L S. Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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Common �f Mass�chusett� RECENM
Ityrr®Wn' TT
t c NOV . 2006
Form 4 ANDOVER
`
HEAL III Ewr
DER has provided this form for use by local Boards of Health. The 1yMM P' rrip'rt'g � ust
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Wheen�flling out 1 System
Location:
forms on the o i
computer,use
only the tab key Address
to move your Nib, O.„Od(j A,)
cursor-do not Cltyfrown State Zip Code
Use the return .
key,.:, �,,, .. ,:•
2. System,Owner:
Name
lugAddress(if different from location)
City/Town State Zip Code
„
Telephone Number
B. Pumping Record
1. Date of Pumping i" 2. Quantity Pumped: Gallons
N pa}e
'Type of system: ❑ Cesspool(s) . ptic Tank ❑ Tight Tank
❑' Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No' If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:'
6. Sy em Pumped Y.
U/1CG '
Name Vehicle License Number
Company
7: : Location where contents,were disposed:
Signature of Hauler Date
http://WWW.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5fomA.doc•06103 System Pumping Record•Page 1 of 1
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TOE OF NORTH ANDOVER
SYSTEM PUMPING RECORD
SYSTEM Y T
E
M OWNER& ADD RESS SYSTEM LOCATION rn
(example: left front of house)
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DATE OF PUMPING:
. QUANTITY PUMPED GALLONS
CESSPOOL. NO_ _ YES_ SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE_ LIZ EMERGENCY
OBSERVATIONS: .. ._.. ...
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GOOD CONDITION' FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
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',SYSTEM PUMPED BY: C/f dv
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, OMMENTS: . . �
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O'VBENTS TRANSFERRED TO:
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