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64-104 - Colonial Road - CONSERVATION COMMISSION Coll �o 1 � -S WON #302 6k.34610 Pg;149 12/22/2015 11:00 COMPLI Pg 113 310 CMR 10.99 DEP File No. 64-104 Form 8 (To be provided by DEP) city/Tmn Salem Applicant Van Waters & Rogers Commonweal th - of Massachusetts Certificate Of Compliance Massachusetts Wetlands Protection Act, G.L. c. 131, §40 From Salem Conservation Commission Issuing Authority To Van Waters & Rogers Colonial Road Salem, MA 01970 (Name) (Address) Date of Issuance January 8, 1998 This Certificate is issued for work regulated by an Order of Conditions issued to Hamblet & Hayes Company dated 8 28.84 and issued by the Salem Conservation Commission 1. Q It is hereby certified that the work regulated by the above- referenced Order of Conditions has been satisfactorily completed. 2 . ❑ It is hereby certified that only the following portions of• the work regulated by the above-referenced Order of Conditions have been satisfactorily completed: (If the Certificate of Compliance does not include the entire project, specify what portions are included. ) 3 . ❑ It is hereby certified that the work regulated by the above- referenced Order of Conditions was never commenced. The Order of Conditions has lapsed and is therefore no longer valid. No future work subject to regulation under the Act may be commenced without filing a new Notice of Intent and receiving a new Order of Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Leave Space Blank) Irv ZSFfc(2l Lf30 Effective 11/10/89 8-1 ti s I certify this to bep true and correct copy of Certificate of Compliance DEP#64- loq. Tom D '� rvation Agent Dat City of alem Department of Planning&Community Development THEIMA NA MI FRANCISC y, dkd � 8� Notary public COMMONWEALTH OF MA88ACNOBETTS Signature of Notary K ublic My Commission Expires j ,�ClJ� June 10. 2021 V Printed Name of Notary Public Place notary seal or stamp above. Jai,,¢ �,1 0 ZAZ/ My Commission E pires(date) 4 .- ❑ The certificate shall be recorded in the Registry of Deeds or the Land Court for the district in which the land is located. The Order was originally recorded on (date) at the Registry of Book Page 5. ❑ The following conditions of the Order shall continue: (Set forth any conditions contained in the Final Order, such as maintenance or monitoring, which are to continue for a longer period. ) Issued by I Signature (s) / e� IL When issued by the Conservation Commission this Certificate must be signed by a majority of is members. On this 8th day of January ig 98 before me personally appeared the above mentioned to me known to be the person described in and who executed the foregoing instrument and acknowledged t7,C-1 she executed the same as his/her free act and deed. , 4f-6.zO 0(:4' r 61 , otary Public My commission expires Detach m dotted line and submit to the Salem Conservation Commission ............................................................................................................. To Issuing Authority Please be advised that the Certificate of Compliance for the project at: File Nuaber has been recorded at the Registry of and has been noted in the chain of title of the affected property on , 19 If recorded land the instrument number which identifies this transaction is If registered land the document nuaber which identifies this transaction is Signature Appticant 5-2 COMP,gOr';r:( P.�TH OF MASSACHUSETTS MASS ESSEX REGW(kY OF DEEDS, SO, DIST.,SALEM, 20 if ESSEX SS pfv-44-- ". A TRUE COPY OF RECORD: BOOK PAGE ATTEST 9� REGISTER 310 CMR 10 . 9D DEP File No. 64-104 Form 8 (To be provided by DEP) City/Torn Salem Applicant Van Waters & Rogers Co=onwealth of Massachusetts Certificate of Compliance Massachusetts Wetlands Protection Act, G.L. c. 131, 540 From Salem Conservation Commission Issuing Authority To Van Waters & Rogers Colonial Road Salem, MA 01970 (Name) (Address) Date of Issuance January 8, 1998 This Certificate is issued for work regulated by an Order of Conditions issued to Hamblet & Hayes Company dated 8.28.84 and issued by the Salem Conservation Commission 1. ® It is hereby certified that the work regulated by the above- referenced Order of Conditions has been satisfactorily completed. 2. ❑ It is hereby certified that only the following portions of the work regulated by the above-referenced Order of Conditions have been satisfactorily completed: (If the Certificate of Compliance does not include the entire project, specify what portions are included. ) 3 . ❑ It is hereby certified that the work regulated by the above- referenced Order of Conditions was never commenced. The Order of Conditions has lapsed and is therefore no longer valid. No future work subject to regulation under the Act may be commenced without filing a new Notice of Intent and receiving a new Order of Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Leave Space Blank) Effective 11/10/89 8-1 4 . ❑ The certificate shall be recorded in the Registry of Deeds or the Land Court for the district in which the land is located. The Order was originally recorded on (date) at the Registry of Book Page 5. The following conditions of the Order shall continue: (Set forth any ' conditions contained in the Final Order, such as maintenance or monitoring, which are to continue for a longer period. ) Issued by J Signature (s) When issued by the Conservation Commission this Certificate must be signed by a majority of is members. On this 8th day of January 19 98 before me personally appeared the above mentioned to me known to be .the . person described in and who executed the foregoing instrument and acknowledged that /she executed the same as his/her free act and deed. otary Public My commission expires Detach on dotted tine and submit to the Salem Conservation Commission ............................................................................................................ To Issuing Authority Please be advised that the Certificate of Compliance for the project at: File NuTber has been recorded at the Registry of and has been noted in the chain of title of the affected property on , 19 If recorded Land the instrument number which identifies this transaction is If registered Land the document number which identifies this transaction is Signature Applicant 6-2 e � A Opd,4 September 12 , 1989 Ms . Kathy Winn Salem Conservation Commission 1 Salem Green Salem, MA 01970 Hamblet & Hayes Company has completed the sewerage pump station and force main at Colonial Road per the order of conditions signed September 27 , 1984 ; DEQE File No. 64- 104 . We are therefore requesting a certificate of compliance be issued by the commission . Sincerely, W. Eric Paskerian, E . I .T . Plant Engineer WEP :mbc We H R iVI �/) FSSIOPILL El`��a`�� 3 Hamblet & Hayes Co. Colonial Road.Salem.n7assachuseus 01970 • (508)74537W Crowley Road,Lewiston.Maine 04240 • (207)783-9121 274 South Main Street,Glove...'ille-New York 12078 0 (518)725-5211 MODIFICATION OF -ORIGINAL ORDER J4 Form 5 DECEFlONo 64-104 - - (rc beprovKWby OEOE) Commonwealth Gryrtown Salem of Massachusetts Arm Hamblet & Hayes Order of Conditions Massachusetts Wetlands Protection Act G.L c. 131, §40 Ftem SALEM CONSERVATION COMMISSION TO Hamblet and Hayes Company , Ciba-Geigy Corporation (Name of Applicant) (Name of property Owrmll Addres9 Colonial Road, Salem Ad s= 444 Sawmill Rd. , Ardsley, N, Y. This Order is issued and delivered as follows: 0 1by hand delivery to applicant or representative an (date) ❑ by certified mad,retum receipt requested on (date) This project is located at Colonial Road, Salem, MA. The property is recorded at the Registry of Essex South Book 3810 page 589 - - - 5627 762 Certificate(if registered) The Notice of Intent for this project was filed on 8-28-84 (date) The public hearing was closed on 9-13-84 (date) Findings The Salem Conservation Commission has reviewed the above-refenenced.Noticeof Intent and plans and has held a public hearing on the project.Based on the information available to the Commission atthistime,the Commission has determined that the area on which the proposed work is to be done is significant to the following interests in accordance with the Presumptions of Significance set forth in the regulations for each Area Subject to Protection Under the Act(check as appropriate): ❑ Public water supply ❑ Storm damage prevention ❑ Private water supply 30 Prevention of pollution ❑ Groundwater supply ❑ Land containing shellfish ❑ Flood control ❑ Fisheries 5-1 95 Therefore,the Commission hereby finds that the following conditions are necessary,in accordance with the Performance Standards set forth in the regulations,to protect those inter- ests chocked above.The Conservation Commission orders that all work shall be performed • in accordance with said conditions and with the Notice of Intent referenced above.To the extent that the fob lowing conditions modify or differ from the plans,specifications or other proposals submitted with the Notice of Intent,the conditions shall control. Ganenl Conditions 1. Failure to comply with al conditions stated herein.and with all remtedstatutes and other.regubdory meas- ures,shall be deemed cause to revoke or modify this Order. 2. This Order does not grant any property rights or any exclusive privileges:M does not authorize any injury to private property or Invasion of private rights. 3. This Order does not relieve the permittee or any other person of the necessity of complying with all other applicable federal,state or local statutes,ordinances,bylaws or regulations. 4. The work authorized hereunder shall be completed within throe years from the date of this Order urdess either of the following apply: (a) the work is a maintenance dredging project as provided forin the Act:or (b) the time for completion has been extended to a specified date more Morn three years,but less than five years,from the date of Issuance and both that date and the special circumstances warranting the extended time period are set forth In this Order. S. This Order maybe extended by the issuing authority for one ormore periods of up to three years each upon application to the Issuing authority at least 30 days prior to the expiration date of the Order. 8. Any fill used in connection with this project shall be clean fill,containing no trash,refuse,rubbish or de- bris.Including but not limited to lumber,bricks,plaster,wire.lath,paper.cardboard,pipe.tires.ashes. refrigerators,motor vehicles or parts of any of the foregoing. 7. No work shall be undertaken until all administrative appeal periods from this Order have elapsed or.if such an appeal has been tiled,until an proceedings before the Department have been completed 8. No work shall be undertaken until the Final Order has been recorded in the Registry of Deeds or the Land Court for the district in which the land is located,within the cheirm of title of the affected property.In the case of record ad land,the Final Order shall also be noted in the Registry s Grantor Index under the name of the anner of the land upon which the proposed work is to be done.In the case of registered land,the Final Order shall also be noted on the land Court Certificate of Title of the owner of the land upon which the proposed work is to be done.The recording into.... n shall be submitted to the Commission on the form at the end of this Order prior to commencement of the work. 9. A sign shall be displayed at the site not less than two square feet or more than three square feet in size bearing the words,"Massachusetts Department of Environmental Quality Engineering. Fie Number 64-104 10.Where the Department of Environmental Quality Engineering is requested to make a determination and to issue a Superseding Order, the Conservation Commission shall be a party to all agency proceedings and hearings before the Department. 1 1. Upon completion of the work described herein,the applicant shall forthwith request in writing that a Certificate of Compliance be issued stating that the work has been satisfactorily completed. 12.The work shall conform to the following plans and special conditions: 5.2 96 Plans: We Dated Signed and Stamped by: On Fie wittc "Proposed Sewage PumpStation - . . and Force Main for Hamblet & Hayes Co. Colonial Rd. , Salem" A. F. Sharry, P. E. Conservation Commission Julv 23, 1984, Rev. August 31, 1984 Special Canditlmo(Use addMw.W paper it necessary) The following changes to articles 1-5 of the existing Order of Conditions are to be considered modifications and not an alteration of the remainder or intent of the original action. 1. Work shall conform to plans entitled, "Proposed Sewage Pump Station and Force Main for Hamblet and Hayes Company, Colonial Road, Salem, MA." and "Sewage and Flow Calculations" prepared by Hancock Survey Associates, dated July 23, 1984, revixed August 31, 1984, and further noted and approved by City Engineer Paul S. Niman on September 10, 1984. 2. Work shall conform to South Essex Sewage District Class 3 Wastewater Discharge ' Permit #05-00171086, dated August 22, 1984. " 3. Prior to commencement of work, an erosion control plan and stockpiled soil storage plan shall be submitted to the Conservation Commission for review and approval: 4. Prior to the discharge of any industrial waste, the Operations and Maintenance Manual for the proposed pre-treatment facility shall be submitted to the Con- servation Commission for their review and approval. 5. Prior to commencement--of pre-treatment facility, a. pfe-treatment plan shall be submitted to the Conservation Commission for review and approval. .......................................................................... .....-.............-......»........... (Learn Space BW*) 5.3A 97 Issued By SALEM Conservation Commission Signatures This Order must be signed by a nmjority of the Conse ivabon CommissiorL On this �h _day pf_ 19 before-rr personally appear = n b i t - r n m ,to me known to be the person described in and who executed the foregoing Instrument and acluv wledged that he/she executed the same ie/her free act and defied. Notary public My Commission expires The appiant.theovmor.any poison aggrieved by Oft Ordw.any owns lath aWltlnO thVio d upon which two 'work a b be done or any ten rosidenta err the city or to"in which such tend is located am hereby.011 of their e4d to request#00epartrnent of Ernkonnnentsl Chdiy Enrglnsermg to awe a Superseding Order,peoiidap theragesst is I byearmodmolorhanddoiveryto Ric DepaNnadwithn ton dayshom Msdateofissuance at this Order.Acopyoftherequed"atthe earns tkrne beead by eardGed . maibrhad delivery to the Conservation Commission and OnappkanL Delaehoe doffed Rneand submit tothe Salem Conservation Commission prior to commencement of work. To _ Issuing Authority . Pismo be advised that^V �oraa of Conditions for the project of File Number has been recorded at the Registry of and has been noted in the chain of title of the affected property in accordance with General Condion 8 on _ 19_ Ir recorded lard. the instrument number which identifies this transaction is If registered land,the document number which identifies this transaction e Signature Applicant 5-4A y,%n Frain f 1 e No.lv f - I LA ��.We_�navQ. Q\any ev�f��lad,pPropoS� S¢wo-'a+-��.�.Q Sta't�o� a� 'moo rc..a Mo.:,n. "• 5 .s Wola DLO Cwk,LA1� ba or :S kvA,e Z�EteS ate, Co,+o Q10, �St'o&yP a d 4/1 -4xQ. PrDPoS¢Qf- MODIFICATION OF ORIGINAL ORDER B�l)� 900X294 -94 - Form 5 _ OECEriMNo. 64-104 (To be provided by WOE) Commonwealth � y—"- CityR,w„ Salem of Massachusetts 1 Hamblet & Hayes 0k1V16RECEIVED Order of Conditions. JUL 1 p t987 Massachusetts Wetlands Protection Act G.L. c. 131, §40 SREM PLANNING DEPT. _ SALEM CONSERVATION COMMISSION Fromm+ TO Hamblet and Hayes Company . Ciba-Geigy Corporation (Name of Applicant) (Name of property owner) Address Colonial Road, Salem Address444 Sawmill Rd. , Ardsley, N, Y. c This Order is issued and delivered as follows. i 0 by hand delivery to applicant or representative on (date) ❑ by certified mail,return receipt requested on (date) • N This project is located at Colonial Road, Salem, MA. W The property is recorded at the Registry of Essex south Book 3810 page 589 5627 762 Certificate(if registered) 0 The Notice of Intent for this project was filed on 8-28-84 (date) o cm The public hearing was closed on 9-13-84 (date) 4-1 M N Findings The Salem Conservation Commission has reviewed the above-referenced Notice of Intent and plans and has held a public hearing on the project.Based on the information available to the Commission atthistime,the Commission has determined that the area on which the proposed work is to be done is significant to the following interests in accordance with the Presumptions of Significance set forth in the regulations for each Area Subject to Protection Under the Act(check as appropriate): ❑ Public water supply ❑ Storm damage prevention ❑ Private water supply )0 Prevention of pollution ❑ Groundwater supply ❑ Land containing shellfish ❑ Flood control ❑ Fisheries x 5-1 7 >3ooR 900�FG295 95 Therefore,the Commission hereby finds that the following conditions are necessary,in accordance with the Performance Standards set forth in the regulations,to protect those inter- ests checked above.The Conservation 'Commission orders that all work shag be performed in accordance with said conditions and with the Notice of Intent referenced above.To the extent that the fol- lowing conditions modify or differ from the plans,specifications or other proposals submitted with the Notice � `fof Intent,the conditions shag control. �.3 a� ifGee�ara'1`y .3 ;tilonm 1. failure to comply with all conditions stated herein,and with all related statutes and other regulatory meas- " V v iurgs',shall be deemed cause to revoke or modify this Order. fir` 2., This Order does not grant any property rights or any exclusive privileges;it does not authorize any injury . t$ tJ11 :spfeWt rivate;Rtopertyor invasion of private rights. 3. This Order does not relieve the permittee or any other person of the necessity of ccmptying with aii other applicable federal,state or local statutes,ordinances,by4aws or reguladem 4. The work authorized hereunder shall be completed within three years from the dateof this Order unless either of the following apply (a) the work is a maintenance dredging project as provided for in the Act;or (b) the time for completion has been extended to a specified date more than three years,but less than five years,from the date of issuance and both that date and the special circumstances warranting the extended time period are set forth in this Order. - ' 5. This Order may be extended by the issuing authority for one ormore periods of up to three years each upon application to the issuing authority at least 30 days prior to the expiration date of the Order. c� 8. Any fill used in connection with this project shag be clean fig,containing no trash,refuse,rubbish or de- bris,including but not limited to lumber,bricks,plaster,wire,lath,paper,cardboard,pipe,tires,ashes, refrigerators,motor vehicles or parts of any of the foregoing. 7. No work shall be undertaken until all administrative appeal periods from this Order have elapsed or,if such an appeal has been filed,until all proceedings before the Department have been completed. 8. No work shall be undertaken until the Final Order has been recorded in the Registry of Deeds or the Land Court for the district in which the land is located,within the chain of title of the affected property.In the case of recorded land,the Final Order shall also be noted in the Registry's Grantor Index under the name - of the ow,isr cf tha land upon which the proposed work is to be done.In the case of registered tand-the Final Order shall also be noted on the Land Court Certificate of Title of the owner of the land upon which the proposed work is to be done.The recording information shall be submitted to the Commission on the form at the end of this Order prior to commencement of the work. 9. A sign shall be displayed at the site not less than two square feet or more than three square feet in size bearing the words."Massachusetts Department of Environmental Quality Engineering. File Number 64-104 10.Where the Department of Environmental Quality Engineering is requested to make a determination and to issue a Superseding Order, the Conservation Commission shall be a party to all agency proceedings and hearings before the Department. 1 1. Upon completion of the work described herein,the applicant shall forthwith request in writing that a Certificate of Compliance be issued stating that the work has been satisfactorily completed. 12.The work shall conform to the following plans and special conddions: 5-2 t 96 BOOK 9001J pZ96 2 .e Plans: Title Dated Signed and Stamped by: On Re with: "Proposed Sewage -Pump. Station - - "and-Force Main for Hamblet & - Hayes Co. Colonial Rd. , Salem" A. F. Sharry, P. E. Conservation Commission Julp 23, 1984, Rev. August 31. 1984 Special Conditions(Use additicral paper it n ec essa:f) The following changes to articles 1-5 of the existing Order of Conditions are to be considered modifications and not an alteration of the remainder or intent of the original action. - - -3. Work shall conform to plans entitled, "Proposed Sewage Pump Station and Force Main for Hamblet and Hayes Company, Colonial Road, Salem, MA." and "Sewage and Flow Calculations" prepared by Hancock Survey Associates, dated July 23, 1984, revixed August 31, 1984, and further noted and approved by City Engineer Paul S. Niman on September 10, 1984. - , 2. Work shall conform to South Essex Sewage District Class 3 Wastewater Discharge Permit #05-00171086, dated August 22, 1984. 3. Prior to commencement of work, an erosion control plan and stockpiled soil storage plan shall be submitted to the Conservation Commission for review and approval. 4. Prior to the discharge of any industriai'waste, the Operations and Maintenance Manual for the proposed pre-treatment facility shall be .submitted to the Con- servation Commission for their review and approval. 5. Prior to ,commencement`of pre.-treatment- facility, a_ pre-treatment,.-plan .sha31 be submitted to the Conservation Commission for review and approval. ........................................................................................................................._..._.-............-..._-.-.�.-...�_--......� (leave Spate Blank) . 5.3A 97 eouK 90u�G297 Issued By_ SALEM Conservation Commission Signatures) �t{n{{ttt�Nf M9. J .a� �- - tip' /v '. O This Order must be signed by a majority of the Conservation Commission. i„`', f ro a ' ,urn, F. On this_ _ .. _day f— personally appeared P n rl u� - n rx p c tome kriowts to he the��' person described in and who executed the foregoing instrument and adofowiedged'that heishe executed } f the same Wher free act and deed Notary Public My commission expves The applicant the awrw.am/pion aggrieved by this Order,any owner of lard abutting to land upon which Me proposed work is to be doe or awry ten residents of the city or town in which such lend is located are hereby notified of their right to request the Department of Emkonmentai Quality Engineering to issue asuperseding Order,providing the request is made by certified mail or hand delivery to the oepertment within ten days from the date of issuance of this Order.A copy of the request shall at the same time be seed by certified mad or hand delivery to the-Co neery ilon Commission and the applicat. • . �Z7 9 Salem Conservation Commission ^ ' Detach on dotted fine and submit to the prior tointar{esmeat of work. To .� F -IssuingAuthonty . Please be advised that th a xcer of Conditions for the project at FIB Number has been recorded at the Registry of and has been noted in the chain of title of the affected property in accordance with General Condition 8 an 19 It recorded land. the instrument number which identifies this transaction is It registered land,the document number.which identifies this transaction is - Signature Applicant 5-4A ,� L1 com commission Salem. Al ssachusetts 01970 F1'•tf.i ti5!��~ ?i- DEQE File 64-104 Date: 7/31/84 PROPOSED PROJECT SliNMARY Applicant : Hamblet and Haves Company--Thomas Andrewskeiwicz Engineer Address: Colonial Road Phone . 745-3700 Location of Property: Colonial Road and Jefferson Avenue Project Description: Install pump station and sewage force main I. Type of Action: Determination of Applicability _XXX Modification of Order Notice of Intent Extension of Order Abbreviated Notice of Intent Certificate of Compliance r H. Interest(s) in the Wetlands Protection Act, M.G.L. c. 131, S. 40 affected: XXX Public or private water supply XXX Ground water supply Xy�� Storm. damage prevention XXX Prevention of pollution Protection of land containing shellfish Protection of fisheries III. Resource areas subject to protection: XXX Bank Ocean XXX Fresh water wetland Estuary _ Coastal wetland Creek Beach _ River bordering on: 100 Year Floodplain Stream _ Dune _ Flat _ Pond Marsh _ Lake XXX Swamp Land under any of the water bodies listed above Land subject to tidal action Land subject to coastal storm flowage XXX Land subject to flooding IV. Comments : At the last Commission meeting held September 13, 1984 the Commission approved this proposal with the conditions shown on the attached Order. Mr. Andrewsciewicz has requested that they be allowed to construct the sewage force main and pump station prior to the discharge of any industrial waste into the system. It is for this reason that the applicant wishes to have Special Conditions 4 and 5 of that Order changed to Conditions 4 and 4 below: V. Proposed conditions: 4. Prior to the discharge of any industrial waste, the Operations and Maintenance Manual for the proposed pre-treatment facility shall be sub- mitted to the Conservation Commission for their review and approval. 5. Prior to the discharge of any industrial waste, a pre-treatment plan shall be submitted to the Conservation Commission for their review and approval. Conservation Aide 9Az4,/*Q' Date 96 Plans: Tile Dated Signed and Stamped by: On File with: =_ccosed Se,.,,age Pump Station a-.d Force Main for Hamblet & .ayes Co Colcnial Rd. . Sp,Am" July23, 1984 Rev. Aug. 31,, 1984 (noted by City Engineer 9-10-84) A.F. Sharry, P.E. Conservation Commission Special Condtcns(Use additional paper ff necessary) 1. Work. shall conform to plans entitled, "Proposed Sewage Pump Station and Force Main for Hamblet and Hayes Company, Colonial Road, Salem, MA. " and "Sewage and Flow Calculations" prepared by Hancock Survey Associates, dated July 23, 1984, revised August 31, 1984, and further noted and approved by City Engineer Paul S. Niman on September 10, 1984. 2, Work shall conform to South Essex Sewage District Class 3 Wastewater Discharge Permit =,05-00171086, dated August 22, 1984. 3. Prior to commencement of work, an erosion control plan and stockpiled soil storage plan shall be submitted to, the Conservation Commission for .review and approval. 4. Prior to commencement of work, the Operations and Maintenance Manual for the p-goosed pump station and orce main shall be submitted to the Conservation Commission for their review and approval. 5. 'rior to' commencement of work, a pre-treatment plan shall be submitted to the Conservation Commission for review and approval. ..........................................----- --...... — ---- ----- (Leave Spce Blank) PQ��—�d44 C-Lyr�a( .j JOB HANCOCK SURVEY ASSOCIATES, INC. 69 Holten Street SHEET NO, OF DANVERS, MASSACHUSETTS 01923 CALCULATED BY DATE (617) 777-3050 CHECKED BY DATE_ SCALE fl , . vnauin i s X,Gaon Me mm. y JOB z� HANCOCK SURVEY ASSOCIATES, INC. 69 Holten Street SHEET NO of DANVERS, MASSACHUSETTS 01923 CALCULATED BY - SM DATE (617) 777.3050 CHECKED BY DATE_ SCALE 171,4 77777777n..- , 1 / �n Owe-. M A�v�l� tact �a1 .L0L n4l- Q &a��^- L 8 � V. c,• IL 4� aoxxi s'fnza Y.. PA00.Cf10t1�Ix,CMm,Mm 01111. /IIO e l e•, � e47 / �� 3d .Se LO S I.ef ♦.eoJ fo � .e 2/ �e e.eseS\ S A /e - Ldd07 4 / /�i .i0 d•/sef h / O O.OeoO'S \ D.00Vo� Q e.0 6 Ro e•e/oeD• 0.4 d.J •S /./eon/ e.a d.3 C \ V y M.O � M.4NN/NC/ J FO,eMULA �QApN/C SOLUT/ON a— � J Forma SAL'EM PLHIi.VIiiG DEPT, DECE File No. (To Abe provided by DEOE) Commonwealth of Massachusetts 4 _ 4 appkant Notice of Intent Under the Massachusetts Wetlands Protection Act, G.L. c. 131, §40 and Application for a Department of the Army Permit Part L General Information 1. Location-Street Address GO l Ca l S I G 1 IZO A Y7 Lot Number 2. Project Type Description PCkG-t P 1 eiTDtTyCa!_i � �Q1LGE I`-Cl`rL4-.l �2O1--i 3. Registry:County, '5�T fL Current Book &Page 5co 2,'l Certificate(It Registered Land) 4. APPlicant 'I�JI + r �4 GrA�� ., . Tel.7r+✓i 3�Q0 Address C;O1..01..1!I,d,L V_0ket? `7444-9:1-I , "Al S ��--�� 5. Property Owner & 112A. - 61F; d 1G,Y LO -P. Tel. pp��//��ry1[L_3131 Address LId LT "- A7xw"ILL W Vl;2 V-Q&l7 t 1r217Gi1_& 1-1 •`/, 10001 6. Representative A 44- L4C-OCA"R `5?-LR-��/ -LeveiG� i It tC. Tel. ITI—WJ0 Address Cry"a F olpi�roh-I Gj T. 1��L-V��tZ�i I }EGA C7{��3 7. Have the Conservation Commission and the DEOE Regional Office each been sent,by certified mail or hand delivery,2 copies of completed Notice of Intent,with supporting plans and documents? 1 Yes 1�a No 0 8. Have all obtainable permits,variances and approvals required by local by-law been obtained? Yes ❑ No 'RP Obtained Applied For. ^tfot99 F� ©\YPITLbd...4175 �isttTt{ SeX �P��>lb�L Gi�r1Eti24Gv� 9. Is any portion of the site subject to a Wetlands Restriction Order pursuant to G.L c.131.§40A or G.L c. 130,§105? Yes ❑ No 10.Llst all plans and suPporting documents submitted with this Notice of Intent. Identifying N mberA.etter Title,Date 1—IO• ?79zp ' -120W OVO ?]A1-'4P Coil-Ol,-lllkL �2.(�1�(� u--k SAd1�1SS �A`T�)� 23 JI�1.64 11.Check those resource areas within which work Is proposed: (a)X ButferZone (b)Inland: ❑ Bank• Land Subject to Flooding, ❑ Bordering Vegetated Weiland* ❑ Bordering ❑ Land Under Water Body&Waterway• ❑ Isolated n (c)Coastal ❑ Land Under the Ocean• ❑ Designated Port Area' ❑ Coastal Beach• ❑ Coastal Dune ❑ Barrier Beach ❑ Coastal Bank ❑ Rocky Intertidal Shore' ❑ Salt Marsh• ❑ Land Under Salt Pond* ❑ Land Containing Shellfish• ❑ Fish Run' •Ukely to involve U.S. Army Corps of,Englr+Pere concurrent jurisdiction.See General Instructions for Completing Notice of Intent. / 3.2 Y Pert II:Site Description Indicate which of the following information has been provided (on a plan,in narrative description or calcula- tions)to clearly,completely and accurately describe existing site conditions. Identifying ✓ ` Number/letter (of plan,narrative or calculations) Natural Features: Soils ✓ Vegetation Topography Open water bodies(including ponds and lakes) Flowing water bodies Qncluding streams and rivers) Public and private surface water and ground water supplies on or within 100 feet of site Maximum annual ground water elevations with dates and location of test Boundaries of resource areas checked under Part I,Rem 11 above Other l/ Man-made Feahxea: Struchxes(such as buildings,piers,towers and headwalls) Drainage and flood control faalities at the site and Immediately off the site,including culverts and open channels (with inverts).dams and dikes Subsurface sewage disposal systems Underground utilities l Roadways and parking areas Property boundaries,easements and rights-of-way Other Part III:Work Description Indicate which of the following information has been provided(on a plan,in narrative description or calcula- tions)to dearly,completely and accurately describe work proposed within each of the resource areas checked In Part 1,Rem 11 above. Identifying Number/Letter 1 �C] ( �D V (of Pin,narrative or calculations) Planview and Cross Section of: Structures(such as buildings,piers,towers and headwalls) 1 Drainage and flood control facilities,including culverts and open channels(with inverts),. dams and dikes Subsurface sewage disposal systems&underground utilities Filling,dredging and excavating,indicating volume and composition of material Compensatory storage areas,where required in accordance with Part 111,Section 10:57 (4)of the regulations Other Point Source Discharge l O-r Ar�P�1G6�h�) IZ. Description of characteristics of discharge from point source(both closed and open channel),when point of discharge falls within resource area checked under Part I,item 11 above,as supported by standard engineering calculations,data and plans,including but not limited to the following: l 3.3 1. Delineation of the drainage area contributing to the point of discharge; / 2. Pre-and post-development peak rurroff from the drainage area,at the point of discharge,for at least the 10•year and 100-year frequency storm; 3. Pre-and post-development rate of infiltration contributing to the resource area checked under Part 1,item 11 above; 4. Fafimated water quality characteristics of pre-and post-development run-off at the point of discharge. Part IV:Mitigating Measures 1. pearly,completely and accurately describe,with reference to supporting plans and calculations where necessary: (a) AC measures and designs proposed to meet the performance standards set forth under each re- source area specified in Part 11 or Part III of the regulations;or (b) why the presumptions set forth under each resource area specified in Part n or Part III of the regula- tors do not apply. 0 coastal Resource Mslypc Ianay6q rasnbernWtr 0 SAN of support docunmb O Coastal Resource Area Type: Iderdlryhg raunber or letter 0 Wand of supportdotum is 3-4 Part V:Additional Information for a Department of the Army Permit ) 1. COE Application No. 2. (to be provided by COE) (Name of waterway) 3. Names and addresses of property owners adjoining your property: 4 4. Document other project WWnativea(l.s.,other loeatlons andlor constrtrctbn methods,perticularfy those. that would emote the discharge of dredged or fa material into waters or wetlands). S. 8'%0 x 11'drawings in planview and cross-section.showing the resource area and the proposed actly, Me within the resource area.Drawings must be to scab and should be clear enough for photocopying. Caofiication is required from the Divsion of Water Pollution Cormok before the Federal permit can be slued. Cauficatiort may be obtained by coftaccng the D)vsim of Water Poluton Control 1 Winter Street BosM \ Massacrmeetts 02108. J Y Vuhere the acwayvolltake place wrhn the area under the Massachusetts apprvued Coastal Zane Management Program.the applicant certifies that hs poposed actiaity con-0es widen and wiilbe conducted in a rnan ner that s consistent wdh the apprv.ed pograrn Infonnaoon povided will be used n evaluatrg the applicmon for a permit arld is made a,matter of public record through ssua-ce of a public nonce. Disclosure of the nformat on "s voluntary. hot ever i necessary nfornlation 's not provided the appkzm cannot be processed nor can a permit be sued. I hereby certify under the pains and penalties of perjury that the foregoing Notice of Intent and accompanying plans,docu is an pporting data are true and complete,to the best of my knowledge. Signature of Applicant Date I�A�ICQGI+ SLk2d: �ji Signature of ppli is R resentative Date FORM -E.<epties to EUo Fars slim approved byBCUSACE• 6 May 196r. NED 100 (TEST)-ni. dee.sent eostaias a joist Dtvvem.st of the Army sad State of M.saseh..atts •pvllestin 1 MAY .82 for a permit to obtain portnissies to perform activities is United States .eters.The Office of M...pmt.4 and B.d6.t (OMB) b.. ..proved tbo.. ....ties. r".lead by the US Army Come of En.i.toss. OMB eo8,ber 0702-0036 &ad t•pirsties date of 00 September 1965 applbr.Tub Statement will be at in 6 point type 3.6 I ❑ Coaaml Reaaurce Ana Type. ldentlfyingnumbe mleftw ❑ bywid of support dawmants 2. C Werty,completely and acaxately describe,with reference to supporting plans and calculations where (a) all measures and designs to regulate work within the Buffer Zone so as to insure that'said work does not alter an area specified in Part 1.Section 10.02(1)(a)of these regulations;or (b) If work In the Buffer Zone will attersuch an area,all measures and designs proposed to meet l the performance standards established for the adocent resource area specified In Part 11 or J Part 10 of these regulations. ❑ C,"WI R",,Ca Am TWO ebrdwed By 1 00*oot fkaan"WyZam IdendtyiV mimberor kbar /� lniand P n�lE-(t ECri ��fs�f &1 17 \�f n�d t)(7 at=powtdoamanfa 3-5 L , I y,j2 �.; 14' e ntrW Cemmetet y RllYq�l ery_ J h / )� B9jP �• Sr J I ch �`J�ti aryy� / LI f�. .n.ya � Danvers 'vj •� Kscn 0 - � 6 y t O I s \ Par i��e/ . e•¢� '�, l� e\� i�\ �K G'¢�q GC � rr C � jj V I SP,a em =:. -�� .J� .... ':, t\ � � � 0� - °h^ M Q eM 40 • SBdLEVS - '-. 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IE ffiP l ( /,et�by _� 1 i • > n �.: ) �" HLAND PARK y�� .`- ❑ �� * o C Page 2 Conditions of Permit I Administrative A. The user shall comply with the SESD Regulations covering discharge. of sewerage, drainage, substances, or waste into the POTN, or with state or federal regulations If more stringent. B. The user shall allow SESD personnel ) access to premises for inspection or sampling as related to conditions of this permit. C. The user shall promptly report to the SESD Monitoring and Enforcement office any changes in location, processes, discharges (quantity or quality) , or chemical storage procedures. D.. The user shall notify the SESD immediately in the event of any accident, negligence or other occurance that results in discharge to the public sewerage system of any wastes or process wastewaters not covered by this permit: notification shall be made immediately by phoning the District at 744-4550. E. The User shall discharge wastewater in comformance with the information contained in the permit application on file with the District. F. The user's di.scharge shall conform to the wastewater flows and characteristics listed on Page 3 of this permit. G. The User shall submit the reports to the District as scheduled and described on Page 4 of this permit. H. The user shall comply with the pretreatment requirements and schedules listed on Page 5 of thi's report. II Pretreatment A. General 1 . Pretreatment systems shall not have a by-pass capability. 2. Ail plans and calculations submitted to SESD for review shall be prepared and stamped by a registered professional engineer (PE) . 3. When installation does not follow approved plans and calculations the permittee ` must submit revisgd. plans and calculations that reflect the as built condition. 4. At the time registered pretreatment plans are submitted to the District for rev ew t ey must be accompan e y an Operations and Maintenance Report. The 0 b M Report will detail. A. who will be in charge of the pretreatment program for the permittee and how the person is qualified for the position; B. who will be in charge of daily operations of the pretreatment system and how the person is qualified for the position; C. who will be responsible for maintenance of the pretreatment system and how the person is qualified for the position; D. a description of the operators duties and time required to perform these duties. E. a detailed description of what procedures are to be followed if there is an accidental spill or upset. F. a detailed description of procedures to follow in case of a system break down that will ensure continued treatment of waste going to the sewer. G. a statement of operating parameters for which the system was designed to operate. H. a description of how all waste products produced by the pretreatment system are to be collected and removed. I . documentation of the means of disposal of all waste products produced by the pretreatment system. J. a schedule of recommended preventative maintenance to ensure the pretreatment plant operation. K. a description of how quality control of the system is going to be achieved. B. pH Systems 1 . the pH recorder for the final effluent must be of the strip chart variety. 2. the recording probe must have a read-out in close enough proximity to allow calibration without leaving the probes locations. 3• the recording probe must be placed in the pool of wastewater formed in front of the primary flow measuring device. 4. the pH probes must be easily accessed to ensure cleaning and calibration. 5• the recording pH system shall have an audio and visual alarm system that will be activated anytime the effluent pH is 1,6.5 or'> 10.5. . 6. the pH recording system shall run continuously, 24 hours a day. 7. the pH strip charts shall be submitted to the District in accordance with the "Uniform Reporting Procedures for pH". r J - 1 Page i LIMITS ON WASTEWATER CHARACTERISTICS 1 . The Permittee is authorized to discharge an effluent to the POTW whose characteristics shall not exceed the values listed herein : EFFLUENT CHARACTERISTICS MAXIMUM/DAY A . pH greater than 6 . 5 less than 10. 5 B . Total Suspended Solids 500 mg/l C . Total Fats , Oils & Grease 100 mg/l D. Sulifides 24 mg/ l E . Total Chromium Cr 4 mg/l F. Lead Pb 0. 6 mg/l G . Mercury Hg 0 . 2 mg/l 2 . The Permittees discharge shall not contribute to a violation of the South Essex Sewerage District ' s NPDES permit. b `A 1 Page 4 REPORTING 1 . pH - The Permittee shall record the pH of the final effluent controlled under permit number At the end of each month, the chart se is to be removed and nt to t e istrict to arrive no later than the 7th of the month. 2. Self-Monitoring - The Permittee shall test, at no expense to the District, the final effluent controlled under permit number 05-00171086 The testing will be quarterly and will be initiated with a quarterly notice from the District indicating: a. the parameters to be tested for; b. the date by which the test results must be back into the District offices. c. unless otherwise stated, all sampling will consist of two 24-hour flow proportional composite samples, 3. Slug or Accidental Discharge Reporting - The Permittee shall ,immediately notify the District by telephone (744-4550) of the occurrence of an unauthorized discharge of any pollutant. This includes an unauthorized discharge due to a failed pretreatment system. Submission of the "Slug or Accidental Discharge Report Form" (copy enclosed) is required within five (5) days of any such occurrence. Page 5 COMPLIANCE SCHEDULE Hamblet & Hayes Co . of Colonial Rd . Salem , Mass . , shall have the necessary facilities in place and operational , to meet the standards listed on Page 3 of this permit , before discharging to the POTW . SOUTH ESSEX SEWERAGE DISTRICT ACCIDENTAL DISCHARGE REPORT FORM NOTE TO INDUSTRIAL USERS: Submission of this form signed by an authorized representative of the firm is required within 5 days of the occurrence. . All upsets due to pretreatment system failures are to be considered an "Accidental Discharge" that require this form to be sent to the District. 1 . Company Name: 2. Address: 3. Person to contact concerning information provided herein: Name: Phone # 4. Name and title of authorized representative: Name: Signature: Title: DESCRIPTION OF THE UNAUTHORIZED DISCHARGE 5. Date of unauthorized Discharge: 6. Duration of Discharge: hours minutes 7. Volume of Discharge: 8. Reason for occurrence of unauthorized discharge: 9. Nature of unauthorized discharge. If laboratory analysis was taken, please include. - - A 10. Corrective actions to be taken to prevent future occurences of unauthorized discharges : r LIST OF PRIORITY POLLUTANTS Compound Name 1 . acenaphthene 2. acrolein 3. acrylonitrile 4. benzene 5. benzidine 6. carbon tetrachloride (tetrachloromethane) 7. chlorobenzene 8. 1 ,2,4-trichlorobenzene 9. hexachlorobenzene 10. 1 ,2-dichloroethane 11 . 1 , 1 , 1-trichloroethane 12. hexachloroethane 13. 1 , 1-dichloroethane 14. 1 , 1 ,2-trichloroethane 15. 1 , 1 ,2,2-tetrachloroet6ane 16. chloroethane 17. bis(chloromethyl) ether 18. 2-chloroethyl vinyl ether (mixed) 19. 2-chloronaphthalene 20. 2,4,6-trichlorophenol 21 . para-chloro meta-cresol 22. chloroform ,(t�ichloromethane) 23. 2-chlorophenol 24. 1 ,2-dichlorobenzene 25. 1 ,3-dichlorobenzene 26. 1 ,4-dichlorobenzene 27. 3,31-dichlorobenzidine 28. 1 , 1-dichloroethylene 29. 1 ,2-trans-dichloroethylene 30. 2,4-dichlorophenol fy 31 . 1 ,2-dichlo'ropropane 32. 1 ,2-dichl6ropropylene (1 ,2-dichloropropene) 33• 2,4-dimethylphenol 34. 2,4-dinitrotoluene 35. 2,6-dinitrotoluene 36. 1 ,2-diphenylhydrazine 37. ethylbenzene 38. fluoranthene r , 39• 4-chlorophenyl phenyl ether 40. 4-bromophenyl phenyl ether 41 . bis(2-chloroisopropyl) ether 42. bis (2-chloroethoxy) methane 43. methylene chloride (dichloromethane) 44, methyl chloride (chloromethane) 45• methyl bromide (bromomethane) 46. bromoform (tribromomethane) 47. dichlorobromomethane 48. chlorodibromomethane 49. hexachlorobutadiene 50. hexachlorocyclopentadiene 51 . isophorone 52. naphthalene 53. nitrobenzene 54. 2-nitrophenol 55. 4-nitrophenol 56. 2,4-dinitrophenol 57. 4,6-dinitro-o-cresol 58. N-nitrosodimethylamine 59• N-nitrosodiphenylamine 60. N-nitrosodi-n-propylamine 61 . pentachlorophenol 62. phenol 63. bis(2-ethylhexyl ) phthalate 64. butyl benzyl phthalate 65• di-n-butyl phthalate 66. di-n-octyl phthalate 67. diethyl phthalate 68. dimethyl phthalate - 69. benzo(a)anthracene (1 ,2-benzanthracene) 70. benzo(a)pyrene(3,4-benzopyrene) 71 . 3,4-benzofluoranthene 72. benzo(k)fluoranthene (11 , 12-benzofluoranthene) 4 73. chrysene .� 74. acenaphthylene 75• anthracene 76' benzo(ghi)perylene(1 , 12-benzoperylene) 77. fluorene 76, phenanthrene 79. dibenzo (a ,h)anthracene(1 ,2,5,6-dibenzanthracene) 80. indeno(1 ,2,3-cd)pyrene(2,3- -phenylpyrene) LIST OF PRIORITY POLLUTA14TS (Cont'd.) 81 . pyrene 82. tetrachloroethylene 83. toluene 84. trichloroethylene 85. vinyl chloride (chloroethylene) 86. aldrin 87.. dieldrin 88. chlordane (technical mixture and metabolites) 89. 4,4' -DDT 90. 4,4' -DDE (p.p' -DDX) 91 . 4,4' -DDD (p,p' -TDE) 92. a-endosulfan-Alpha 93• b-endosulfan-Beta 94. endosulfan sulfate . 95. endrin 96. • endrin aldehyde 97. heptachlor 98. heptachlor epoxide : 99. a-BHC-Alpha . 100. b-BHC-Beta 101 . r-BHC (lindane)-Gamma 102. 9-BHC-Delta 103• PCB-1242 (Arochlor 1242) 104. PCB-1254 (Arochlor 1254) 105. PCB-1221 (Arochlor-1221) 106. PCB-1232 (Arochlor 1232) 107• PCB-1248 (Arochlor-1248) 108. PCB-1260 (Arochlor-1260) 109. PCB-1016 (Arochlor 1016) 110. toxaphene Ill . antimony (total) 112. arsenic (total) 113. asbestos (fibrous) 114. beryllium (total) _ 115. cadmium (total) 116. chromium (total) e 117. copper (total) 118. cyanide (total) 119. lead (total) 120. mercury (total) 121 . nickel (total) 122. selenium (total) 123. silver (total) 124. thallium (total) 125• zinc (total) *126. 2,3,7,8-tetrachlorodibenzo-p-dioxin *Because of its extreme toxicity to' lab personnel , this compound is not to bettested for. REVISED UNIFORH REPORTING PROCEDURE: pH In an attempt to standardize reporting procedures, the District requests that all industries conform to the uniform procedure by indicating, as a minimum, the following on each strip chart: 1 . Indicate instrument pH range i P H, ,ili i j, P N4 i:i at beginning of month. j 0 C ,6 2. Date and time of chart installation. 3. Date and time, at beginning and end I O '';; of each workday. Indicate if it is ' a 24 hr. operation. C C 7. I i; 0 7: 4. Clean and calibrate the instrument with standard pH buffers as needed. Frequent C i � cleaning tends to prolong probe life. : ' j If 5. Write firm name on both ends of chart. C CL � I � 'Il P jo�'' . � 6. Indicate equipment malfunctions and C, � ��' •j j notify S.E.S.D. I a.m t a i 7: The recording instrument is to run C • continuously 24 hrs/day, 7 days/week. Please review the above procedures and instruct your operating personnel accordingly. Post this in an accessible location near the pH system for their referral . For proper operation, the pH control system requires periodic maintenance. Equipment failure and running out of caustic will not be acceptable reasons for achieving less than the required compliance for the month. As before, SESD requests that strip charts recording effluent pH be submitted to the District monthly. A new chart should be installed on the lst day of the month, removed on tfie last day, and received at the District office not later than the 7th day of the following month. SOUTH ESSEX SEWERAGE DISTRICT William N. Lazari s June 20, 1984 Assistant Chief of Enforcement a PERMITTEE: M,,bl et 5 Ha3jes rn PERMIT# n5_nn17l npF Colonial Rd . PERMIT CLASS: 3 Salem, Mass . 01970 EXPIRATION DATE: 10- 10-86 Bruce L . Schall Gentlemen: Pursuant to Federal , State and local regulations, the Permittee is hereby granted a Class _ 2 Wastewater Discharge Permit (WDP) . A Class 3 permit authorizes the Permittee to discharge waste into the South Essex Sewerage District POTW, subject to the conditions set forth in this permit. This permit may be modified by the South Essex Sewerage District (SESD) as authorized by the SESD Sewer Use Regulations, or as required by the State or Federal governments, or agencies thereof. a Failure on the part of the Permittee to fulfill any of this permit's specified conditions shall be sufficient cause for immediate revocation of this permit and thereby access to the sewer system. APPROVED: SOUTH ESSEX SEWERAGE DISTRICT Signature: Name: Craig Stepno Title: Chairman, SESD Board Date: August 22, 1984 PRIORITY POLLUTANT STATEMENT The Permittee is advised that the South Essex Sewerage District' s Permit to discharge to the harbor, (known as the National Pollution Discharge Elimination System or NPDES Permit) , is under review as part of the District' s .attempt to receive a waiver from building a secondary treatment facility. When the new NPDES Permit is issued to SESD, it will cause a review of priority pollutants within the sewer system and its receiving waters in the harbor. If the review finds the need to further control pollutant discharges, and the Permittee has pollutants in his discharge, controls of the pollutant discharge will be required. The EPA has not given the District any clear indication when a new NPDES permit can be expected. Therefore, we cannot give the Permittee any indication when controls of pollutant discharges will be required. However, the list of priority pollutants attached to the back of this permit should be reviewed with an eye towards elimi- nating or restricting the discharge of any of the chemicals listed. . .S 314 CMR: DIVISION OF WATER POLLUTION CONTROL One Winter Street 7.20• Boston Ma 02108 PERMIT NO: APPLICATION FOR PERMIT TOWN: FOR For issuing office SEWER SYSTEM EXTENSION OR CONNECTION use only: INSTRUCTIONS The application should be signed by the appropriate municipal official, and submitted in triplicate, with the original and one copy to the Division's Boston office and one copy to the appropriate regional office. The signature of the design engineer .or other agent will be accepted only if accompanied by a letter of authorization. If connection is to be made to the MOC sewerage system, indi- cate "MOC" in item 11. If the project includes sewers, pumping stations, force mains, or syphons, construction plans must be submitted with the application. If additional space is required to properly answer any questions, please attach additional. sheets and refer to the attachments in the space provided: (1) Name and Address of Applicant: 4VAkh-051. -r 'r 1-4-10-Z co , Telephone ram— 3100 (2) Name of Sewer System Owner: 6", ( or- (Municipality or Sewer istrict) (Department) (3) Type of Project: C01—Ft 4EGT127i- i (Sewer xtension or Sewer Connection) (4) Number of Residences to be A served: (5) Number of Bedrooms: 1 ' 16 - 1.i : a . �oTQ� (GA15t 314 CMR: DIVISION OF WATER POLLUTION CONTROL (15) List, in descending order of significance, the four (4) digit standard industrial classification (SIC) Codes which best describe the facility producing the discharge in terms of the principal products or services provided. Also, specify each classification in words. SIC CODE SPECIFY A. 2815 MAuwFAcTUPEk OF /NouS?hIAL C//£LVCALS B. SIG f )1S7r11;u71o1kJ of cN6041CAL b#-.70 AweD '01w4c7s C. D. (16) Is the Proposed Discharge Consistent with Existing Sewer Use Regulations: Yes: / No: (17) Is there a site of historic or archeological significance, as. defined in regulations of the Massachusetts Historical Commission, 950 CMR 71.00, which is in the area affected by the proposed extension or connecton? Yes: No: (18) Does this project require a filing under 301 CMR 10.00, the Massachusetts Environmental Policy Act? Yes No If Yes, Has a Filing been Made? Yes No (19) Name and Address of Massachusetts Registered Professional Engineer Designing the Proposed System: Name A�aress � City State ZAP "Il�-3D�J4 Telephone Mass. P.E. Number 19 - 314 CMR: DIVISION OF WATER POLLUTION CONTROL (20) Certification "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information sub- mitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations." 6nVeC- L Sctk1\ -L 2: tS-3200 Name Official it a Phone No. AA -05 Signature Datd Signed (21) General Conditions (a) All discharges authorized herein shall be consistent with the terms and conditions of this permit and the approved plans and specifications. The discharge of any wastewater at a level in excess of that identified and authorized by this permit shall constitute a violation of the terms and conditions of this permit. Such a viola- tion may result in the imposition of civil and/or crimi- nal penalties as provided for in Section 42 of the State Act. (b) After notice and opportunity for a hearing, this permit may be modified, suspended, or revoked in whole or in part during its term for cause including, but not limited to, the followiII: - 1. Violation of any terms or conditions of the permit; 2. Obtaining a permit by misrepresentation or failure to disclose fully all relevant facts; and 3. A change in conditions or the existence of a con- dition which requires either a temporary or permanent reduction or elimination of the authorized discharge. - 20 - 314 CMR: DIVISION OF WATER POLLUTION CONTROL (c) In the event of any change in control or ownership of facilities from which the authorized discharges origi- nate, the permittee shall notify the succeeding owner or operator of the existence of this permit by letter, a copy of which shall be forwarded to the Director. Succeeding owners or operators shall be bound by all the conditions of this permit, unless and until a new or modified permit is obtained. M The issuance of this permit does not convey any property rights in either real or personal property, or any exclu- sive provileges; nor does it authorize or relieve the permittee of any liability for any injury to private pro- perty or any invasion of personal rights; nor any infringement of Federal , State, or local laws or regulations; nor does it waive the necessity of obtaining any local assent required by law for the discharge authorized herein. (e) The provisions of this permit are severable, and the invalidity of any condition or subdivision thereof shall not make void any other condition or subdivision thereof. (f) All information and data provided by an applicant or a permittee identifying the nature and frequency of a discharge shall be available to the public without restriction. All other information (other than effluent data) which may be submitted by an applicant in connec- tion with a permit application shall also be available to the public unless the applicant or permittee is able to demonstrate that the disclosure of such information or particular part thereof to the general public would divulge methods or processes entitled to protection as trade secrets in accordance with the provisions of M.G.L. c.21, s.27(7). Where the applicant or permittee is able to so demonstrate, the Director shall treat the infor- mation or the particular part (other than effluent data) as confidential and not release it to any unauthorized person. Such information may be divulged to other offi- cers, employees, or authorized representatives of the Commonwealth or the United States Government concerned with the protection of public water or water supplies. (g) Transfer of Permits 1. Any sewer system extension or connection permit authorizing an industrial discharge to a sewer system is only valid for the person to whom it is issued, unless transferred pursuant to 314 CMR 7.13. Such permits shill be automatically transferred to a iew permittee if: - 21 - 314 .CMR: DIVISION OF WATER POLLUTION CONTROL A. The current permittee notifies the Director at least 30 days in advance of the proposed transfer date; and B. The notice includes a written agreement between the existing and new permittees containing a speci- fic date for transfer of permit responsibility, coveraage, and liability between them. 2. Any sewer system extension or connection permit not subject to 314 CMR 7.13(1) automatically trans= fers to a subsequent owner, operator, or occupant. (22) Special Conditions a•' APPROVAL RECOMMENDED: Signature and Title of Appropriate Municipal Official (Phone) FOR ISSUING OFFICE USE ONLY Date Issued Director Division of Water Pollution Control Effective Date ot Permit - 22 - 314 CMR: DIVISION OF WATER POLLUTION CONTROL (6) Other establishments to be served: Name Address ~ Type of Establishment Design Flow yam' co l'a"G m,. 90M? e�2 (7) Design Flow-Gallons Per Day: Sewage �5d0 Industrial Wastes l�D Total 3 :3 00 (8) Location, Length, Size and Capacity of Sewers to be Connected to the existing system: (Attach sketch) (a) �'nl nI ( tD�1_ 1Z17 J ��g�it�1-� d�J�. . Name of Street Length of ewer Size of Sewer F owow F1�Capacity oner (9) Location, Size and Capacity of Pumping Stations to be Connected to the existing system: ump tation Location Num ear of PumpsPum-�ize Pump apacity. ram' @° - 17 - i ! 314 CMR: DIVISION OF WATER POLLUTION CONTROL (10) General Description of Sewers and Pump Stations within the existing sewer system which will transport the flow from the proposed sewer extension or connection to the receiving Wastewater Treatment Facility: 6001r`f SEWER (11) Receiving Wastewater Treatment Facility: SpUT6l F-'�'��i�X h1i�v�tLDI�� 1�ih'T17.iGT Name: \VtkTV,Ct- 1k31rL. TIQ1.1 COOTILOU -FL8 µ-T Average Daily Flow: 2{{ Million Gallons Per Day Design Flow: ,' "f Million Gallons Per Day (12) Does the discharge contain any industrial waste? Yes _ No If yes, list any pollutants which you know or have reason to believe are discharged or may be discharged. For every pollutant you list, please indicate its approximate con- centration in the discharge and any analytical data in your possession which will support your statement. Additional wastewater analysis may be required as part of this applica- tion. ( SE& ATrk,-o F_. yr 1 (13) Does the discha:-ge contain any industrial waste containing substances or materials which could harm the sewers, wastewater treatment process, or equipment; have an adverse effect on the receiving waters; or could otherwise endanger life, limb, public property, or constitute a nuisance? X Yes [;SEE txm_ 6Cto Na (14) Do the wastewaters receive any pretreatment prior to discharge? Yes No - 18 - AbE : TWE '77Rf-,47'6Ab DtSCIM06E AS afSiGNEIJ wtLL CvNPoIaM 7v TttE TOLFk . #E OES u s Emcr A01) T/fERE R'pE S&MLD .)u.W BE DETRIMEOML TM ME AFWEMENT/ONrrFA CoNSTIT,.-&jrS /N PAP"'?AP/F ((13 , 1 ATTACHMENT 1 The following pollutants may be in the Hamblet & Hayes industrial waste discharge at the indicated levels. pH 6.5 - 10.5 BOD5 <500 Mg/L Oil & Grease < 100 Mg/L Total suspended solids <500 Mg/L Total sulfides < 24 Mg/L Total chromium < 4 Mg/L Arsenic <1.4 Mg/L Cadmium <1.2 Mg/L Copper <4.5 Mg/L Lead <0.6 Mg/L Nickel <4.1 Mg/L Silver < 1.2 Mg/L Zinc < 30 Mg/L Total Cyanide <1.9 Mg/L Phenol < 0.072 Mg/L Boran < 10.3 Mg/L Tin < 3.0 Mg/L Total Phosphate <. 0.10 Mg/L Sulfite 15 Mg/L 96 Plans: Title Dated Signed and Stamped by: On File with: "Proposed Sewage .Pump Station - and Force Main for Hamblet & Hayes Co. Colonial Rd. , Salem" A. F. Sharry, P. E. Conservation Commission Julv 23, 1984 Rev. August 31. 1984 Special Conditions(Use additional paper ff necessary) The following changes to articles 1-5 of the existing order of Conditions are to be considered modifications and not an alteration of the remainder or intent of the original action. 1. Work shall conform to plans entitled, "Proposed Sewage Pump Station and Force Main for Hamblet and Hayes Company, Colonial Road, Salem, MA." and "Sewage and Flow Calculations" prepared by Hancock Survey Associates, dated July 23, 1984, revixed August 31, 1984, and further noted and approved by City Engineer Paul S. Niman on September 10, 1984. 2. Work shall conform to South Essex Sewage District Class 3 Wastewater Discharge Permit #05-00171086, dated August 22, 1984. 3. Prior to commencement of work, an erosion control plan and stockpiled soil storage plan shall be submitted to the Conservation Commission for review and approval. Y Prior to the discharge of any industrial waste, the Operations and Maintenan 0 �Y�lanual for the proposed pre-treatment facility shall be submitted to the me Con- servation � n/ � �•/'.//(V� Commission for their review and approval. hRz „\\JV .� Prior to the a pre-treatment plan shall be submitted to the Conservation Commission for review and approval. ........................................................................._.............................._...................._. ......_. (Leave So B Blank) 53A 96 Plans: Title Dated Signed and Stamped by: On File with: "Proposed Sewage .Pump Station and Force Main for Hamblet & Hayes Co. Colonial Rd. , Salem" A. F. Sharry, P. E. Conservation Commission July 23, 1984, Rev. August 31, 1984 Special Conditions(Use additional Paper if necessary) The following changes to articles 1-5 of the existing Order of Conditions are to be considered modifications and not an alteration of the remainder or intent of the original action. 1. Work shall conform to plans entitled, "Proposed Sewage Pump Station and Force Main for Hamblet and Hayes Company, Colonial Road, Salem, MA." and "Sewage and Flow Calculations" prepared by Hancock Survey Associates, dated July 23, 1984, revixed August 31, 1984, and further noted and approved by City Engineer Paul S. Niman on September 10, 1984. 2. Work shall conform to South Essex Sewage District Class 3 Wastewater Discharge Permit #05-00171066, dated August 22, 1984. 3. Prior to commencement of work, an erosion control plan and stockpiled soil storage plan shall be submitted to the Conservation Commission for review and approval. 4. Prior to the discharge of any industrial waste, the Operations and Maintenance Manual for the proposed pre-treatment facility shall be submitted to the Con- servation Commission for their review and approval. 5. Prior to the discharge of any industrial waste, a pre-treatment plan shall be submitted to the Conservation Commission for review and approval. ...................................................................---•- . ..(Leave Space Blank) . 5-3A _ I •Y- ^y V Forth 5 DEDE F&No. 64-104 . . (To be provided by DEDE) SALEM Commonwealth cityrroWrl of Massachusetts p Ha-nblet and Haves Co'. 6 Order of Conditions Massachusetts Wetlands Protection Act G.L c. 131, §40 Fr SALEM CONS£RVATI N ° T Hamblet and Hayes Company Ciba-Geigy Corporation To (Name of Applicant) (Name of property owner) Colonial Road, Salem Addr 444 Sawmill Road, Ardsley, N.Y. Address - This Order is issued and delivered as follows: -- ❑ lby hand delivery to applicant or representative on (date) ❑ (date) by certified mall, return receipt requested on This project is located Pt Colonial Road, Salem, My. The property is recorded at the Registry of £s sex South 3810 g 589 Book Pa e 5627 762 Certificate(if registered) The Notice of Intent for this project was filed on 8-28-84 (date) The public hearing was closed on 9-13-84 (date) Findings SALEM CONSERVATION COMMISSION has reviewed the above-referencad Notice of The Intent and plans and has held a public hearing on the project-mm Based ion n the information has available Hero determined that ('nm at this time, the the area on which the proposed work is to be done is significant to the following Interests in accordance with the Presumptions of Significance set forth in the regulations for each Area Subject to Protection Under the Act(check as appropriate): ❑ Public water supply ❑ Storm damage prevention ❑ Private water supply fr Prevention of pollution ❑ Ground,water supply ❑ Land containing shellfish ❑ Flood control ❑ Fisheries 5-t e 95 Therefore,the Commissicn hereby finds thatthe following conditions are ds set forth in the regulations.to protect thoseinter- necessary, in accordance with the Performance Standar Conservation Commission orders that all work shall beperforrned ests checked above.The the Notice of Intent referenced above.7o the extent that the foi- in accordance with said conditions and with r other proposal submitted with the Notice lowing conditions modify or differ from the plans,specifications o of Intent,the conditions shall control- General Canditions 1. Failure to comply with all conditions stated herein, and with all related statutes and other regulatory meal ures,shall be deemed cause to revoke or modify this Order. 2. This Order does not grant any Property rights or any exclusive Privileges:it does nat authorize any iiri + to private property or invasion of private rights. 3. This Order does not relieve the permittee or any other peen of the necessity of complying with aC other applicable federal.state or local statutes,ordinances.by4a` s or regulations- 4. The work authorized hereunder shall be completed within three years from the data of this OFber unless either of the following apply for in the Ad;or (a) the work is a maintenance dredging project as Provided (b) the time for completion has been extended to a specified date more than three years,but less than five years,from the date of issuance and both that date and the special circumstances ware anling the extended time period are set forth in this Order• ed by the issuing authority for one or more periods of up to three Years each 5. This Order may be extend Prior to the expiration date of the Order. upon application to the issu'iing authority at least 3C days 8. Any fill used in connection with this Proj�shall be dean fill,containing no trash, refuse,rubbish or de- bris, including but not limited to lumber,bricks,plaster,wire,lath,paper.cardboard.P'Pe•bras, ashes, refrigerators, motor vehicles or parts of any of the foregoing. 7. No work shall be undertaken until all administrative appeal periods from this Order have elapsed or,if such an appeal has been filed,until all proceedings before the Department have been completed. 8. No work shall be undertaken until the Final Order has been recorded in the Registry of Deeds or theme d Court for the district in which the land is located,within the chain of tine of thheaffoacted PraPIndex t derthe name case of recorded land, the Final Order shall also be noted in the Registry of the owner of the land upon which the proposed worts is to be done. In the case of registered land,hthe Final Order shall also be noted on the Land Court Certficate of Title of the owner of the land upon,nn ich the proposed work is to be done.The recording information shall be submitted to the =�Z-J— on the form at the end of this Order prior to commencement of the work- not A sign shall be displayed at the site not less than two square feet or more than three square feet in size _ bearing the words, "Massachusetts Department of Environmentai Quality Engineering, File Number 64-104 10.Where the Department of Environmental Quality Engineering is requested to make a detemination and to issue a Superseding Order, the Conservation Commission shall be a party to all agency proceedings _ and hearings before the Department �.. Upon completion of the work•described herein, the applicant shalt forthwith request in writing a a Certificate of Compliance be issued stating that the work has been satisfactorily completed. 12.The work shall conform to the following plans and special conditions: 5-2 96 Plans: Title Dated Signed and Stamped by: On File with: "Proposed Sewage Pump Station and Force Main for Hamblet & Hayes Co Colonial Rd. . as Pm" July23, 1984 Rev. Aug. 31, 1984 (noted by City EnainePr 9-10-84) A.F. Sharry, P.E. Conservation Commission Specal Conditions(Use additional paper R necessary) 1. Work shall conform to plans entitled, "Proposed Sewage Pump Station and Force Main for Hamblet and Hayes Company, Colonial Road, Salem, MA. " and "Sewage and Flow Calculations" prepared by Hancock Survey Associates, dated July 23, 1984, revised August 31, i984 , and further noted and approved by City Engineer Paul S. Niman on September 10, 1984. 2. 'Fork shall conform to South Essex Sewage District Class 3 Wastewater Discharge Permit r05-0011,1086, dated August 22 , 1984. 3. Prior to commencement of work, an erosion control plan and stockpiled soil storage plan shall be submitted to-., the Conservation Commission for .review and approval. 4. Prior to commencement of work, the Operations and Maintenance Manual for the proposed pump station and force -main shall be submitted to the Conservation Commission for their review and approval. 5. Prior to commencement of work, a pre-treatment plan shall be submitted to the Conservation Commission for review and approval. ..........................................................-................... ........ .. (Leave Space BLa k) 5.3A Is-sued By SALEM Conservation Commission Signature(s) i � J V t. Thi rder rttusi be s gn. by a majority of the Conservation Commission. On this day of 19 before me personally appeared to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her tree act and deed- Notary Public My commission expires The applicant,the owner.arry person aggrieved by this order,arty owner of lard aburdng ttw Land upon yr*;h the pvpceed worn is to be done or any tan residents of the city or town in which such land is located are hereby notified of theirnght to request the Deparlmerd _ of Ewronmenw Ouauy av heer ng to issue a supersedng Order,providing the request is made by certified me&or hand delivery to Lie Departmw"within ten days from the date of isarsnre.of this Order.A copy at itre kx,+eat shall at tics same lane be sent by certified mei or hard delivery to the Coruarvabon Commission and the appanL Detach on dotted IIne■rd aubmit to tho Conservation Corranission prior tocommenoemerrt of weir_ lssuing Authority To Please be advised that the Order of conditions for the proiect a and Ale Number has been recorded at the Registry of has been noted in the chain of title of the attecteo property in accordance with General Condition 8 on t 9— h tl recorded land. the instrument number which identifies this transaction is It registered land•the document numbe:which identifies this transaction' Applicant Signature 5-4A MODIFICATION OF -ORIGINAL ORDER 94 Forn 5 DECEFfeNo. 64-104 (To be provided by DEOE) Commonwealth Citylry n Salem of Massachusetts AGW+'d Hamblet & Hayes 9 Order of Conditions. Massachusetts Wetlands Protection Act G.L c. '13'1, §40 SALEM CONSERVATION COMMISSION Fro. To Hamblet and Hayes. Company . Ciba-Geigy Corporation (Name of Applicant) (Name of property owner) Address Colonial Road, Salem Address 444 Sawmill Rd. , Ardsley, N, Y. This Order is issued And delivered as follows: U by hand delivery to applicant or representative on (date) ❑ by certified mail,return receipt requested on (date) This project is locatednt Colonial Road, Salem, MA. The property is recorded at the Registry of Essex South Book }810 Paso 589 5627 762 Cartificate(if registered) The Notice of Intent for this project was filed on 8-28-84 (date) The public hearing was closed on 9-13-84 (date) Findings The Salem Conservation Commission has reviewed the above-referenced Notice of Intent and plans and has held a public hearing on the project. Based on the information available to the Commission at this time, the Commission has determined that the area on which the proposed work is to be done is significant to the following interests in accordance with the Presumptions of Significance set forth in the regulations for each Area Subject to Protection Under the Act(check as appropriate): ❑ Public water supply ❑ Storm damage prevention ❑ Private water supply )0 Prevention of pollution ❑ Ground water supply ❑ Land containing shellfish ❑ Flood control ❑ Fisheries 5-1 K. 95 Therefore,the Commission hereby finds that the following conditions are necessary,in accordance with the Performance Standards set forth in the regulations,to protect those inter- ests checked above.The Conservation Commission orders that all work shall be performed in accordance with said conditions and with the Notice of Intent referenced above.To the extent that the fol- lowing conditions modify or differ from the plans,specifications or other proposals submitted with the Notice of Intent,the conditions shall control. General Conditions' 1. Failure to comply with all conditions stated herein,and with all related statutes and other regulatory meas- ures,shall be deemed cause to revoke or modify this Order. 2. This Order does not grant any property rights or any exclusive privileges;it does not authorize any injury to private property or invasion of private rights. 3. This Order does not relieve the permittee or any other person of the necessity of complying with a9 other applicable federal,state or local statutes,ordinances,byaaws or regulations. 4. The work authorized hereunder shall be completed within three years from the date of this Order unless either of the following apply (a) the work is a maintenance dredging project as provided twin the Act;or (b) the time for completion has been extended to a specified date more then three years,but less than five years,from the date of issuance and both that date and the special circumstances warranting the extended time period are set forth in this Order. 5. This Order may be extended by the issuing authority for one or more periods of up to three years each upon application to the issuing authority at least 30 days priorto the expiration date of the Order. 6. Any fill used in connection with this project shall be clean fill,containing no trash,refuse,rubbish or de- bris,including but not limited to lumber,bricks, plaster,wire,lath,paper,cardboard,pipe,tires,ashes. refrigerators, motor vehicles or parts of any of the foregoing. 7. No work shall be undertaken until all administrative appeal periods from this Order have elapsed or,it such an7appeai has been filed,until all proceedings before the Department have been completed. 8: No work shall be undertaken until the Final Order has been recorded in the Registry of Deeds or the Land Court for the district in which the land is located,within the chain of title of the affected property.In the case of recorded land,the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land upon which the proposed work is to be done.In the case of registered land,the Final Order shall also be noted on the Land Court Certificate of Title of the owner of the land upon which the proposed work is to be done.The recording information shall be submitted to the Commission on the format the end of this Order prior to commencement of the work. 9. A sign shall be displayed at the site not less than two square feet or more than three square feet in size bearing the words,"Massachusetts Department of Environmental Quality Engineering, File Number 64-104 10. Where the Department of Environmental Quality Engineering is requested to make a determination and to issue a Superseding Order, the Conservation Commission shall be a party to all agency proceedings and hearings before the Department. 1 1. Upon completion of the work described herein, the applicant shall forthwith request in writing that a Certificate of Compliance be issued stating that the work has been satisfactorily completed. 12.The work shall conform to the following plans and special conditions: 5-2 P Y 96 Plans: Title Dated Signed and Stamped by: On Re with: "Proposed Sewage .Pump Station and Force Main for Hamblet & Hayes Co. Colonial Rd. , Salem" A. F. Sharry, P. E. Conservation Commission July 23, 1984, Rev. August 31, 1984 Special Conditions(Use additional paper R necessary) The following changes to articles 1-5 of the existing Order of Conditions are to be considered modifications and not an alteration of the remainder or intent of the original action. 1. Work shall conform to plans entitled, "Proposed Sewage Pump Station and Force Main for Hamblet and Hayes Company, Colonial Road, Salem, MA." and "Sewage and Flow Calculations" prepared by Hancock Survey Associates, dated July 23, 1984, revixed August 31, 1984, and further noted and approved by City Engineer Paul S. Niman on September 10, 1984. 2. Work shall conform to South Essex Sewage District Class 3 Wastewater Discharge Permit #05-00171086, dated August 22, 1984. 3. Prior to commencement of work, an erosion control plan and stockpiled soil storage plan shall be submitted to the Conservation Commission for review and approval. 4. Prior to the discharge of any industrial waste, the Operations and Maintenance Manual for the proposed pre-treatment facility shall be submitted to the Con- servation Commission for their review and approval. 5. Prior to commencement_of pre-treatment facility, a pte-treatment plan shall be submitted to the Conservation Commission for review and approval. ........................................................................-........................................._.._......_�._......----- (Le space Blank) 5.3A 97 Issued By SALEM Conservation Commission Signature(s) This order must be signed by a majority of the Conservation Commission. On th*a f day Qf C��wrn 19 before me .. personany appeared �l- n h�r i , - h o m-, to me known to be the person described in and who executed the foregoing Instrument and acknowiedged that he/she executed the same as"hWherfree act and deed. Notary Public / / My commission expires The applicant.the owner,airy person aggrieved by this Order,any owner of land aGMfng dw iartd upon which the proposed work Is to be done or ary ten residents of the city or town in which such land is located are hereby notified of their ngtd to request the Department of Emionmmtal Quality Engineering to issue a Superseding Order,Providing the request is made by certified mail or hand dernery to ttre oepe tment within ten days from the data of issuance of this Order.A copy of the request steal at the same time be sent by certified mail or hard deWery to the Conservation Co massiat and the applicant. ' 4 Detach on lotted Ilse andsubmit to the Salem Conservation Commission P m prior to comeoernent of work. - To Issu'vtg Aurhonty Please be advised that tho order of Conditions for the project at File Number has been recorded at the Registry of and has been noted in the chain of title of the affected property in accordance with General Condition 8 on - 19_ If recorded land, the instrument number which identifies this transaction is It registered land, the document dumber which identifies this transaction is - Signature Appficant 5-4A