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0162 FEDERAL STREET - Street Files 162 Federal Street Health and Education Services 97 Serving Eostern Mossochusetts and Cope Cod December 6, 2006 Salem Fire Department 48 Lafayette St. Salem, KA 01970 Attn: Fire Chief David Cody Dear Chief Cody: I am writing to advise you that Atlas Alarm Corporation is no longer testing or servicing the fire alarm system at the following location: St. James Church . .... . . .. Master Box #437 156-162 Federal Street Salem, MA ,01970 Please remove this location from your list of locations tested by Atlas Alarm Corporation. We hope to have been of service to you. Should you have any questions please do not hesitate to call me. Very truly yours, Atl Corporation Rob . Donahue Inspection Supervisor RFD:mod Corporate Offices • 1239 Washington Street • Weymouth,Massachusetts 02189 • (781)337-8866 Cape Cod Office • 659A Teaticket Highway • Falmouth,Massachusetts 02536 • (508)540-5507 I Cityfo --Sat F-m, �a:i:iacfiuIF-ttI � �LZE L�E�a�fmEn.� �Ae_' — � 1.CifayEttE �tZEEt . MINg Qp f� SafEm dMassacgusetts org7u-3695 J� n�/. JUZ me, �i¢E J tEVE11tLOlZ o9c-tt , �s�5oS-744-1235 n —fi1EI[ 9az 505-745-4646 jI3u2Eau 50S-744_6990 50 -745-7777 SCHOOL FIRE DRILL REPORT Name of School: Address: Date of drill: Time of drill: )000 Length of dri11: Number of school personnel participating: �© Number of students participating: Type of drill: (circle one) gula Blocked Exit Blocked Stairway & Floor (A) (B) (C) Time of recall of students: Fire drill discipline: b`6 6 Weather conditions: S Person initiating drill: AwD Remarks: Signature of principal: Signature of Fire Official: Form 5A (Rev. 09/90) y r SALEM FIRE DEPARTMENT INSPECTION AND VIOLA TION REPORT DATE: 9 V STATION: ADDRESS: C,? -e ,e I NAME: e*- vc S' r PHONE: BLDG.CLASS: I ALARM CO: !>1 OFFICER: F/F: rc, e_e I F/F: MULTIPLE BUSINESSES,RETAIL SPACES,OFFICES,ETC. C OCCUPANCY PHONE#,97,p-- OCCUPANCY PHONE # EXTERIOR PA FAIL N/A HEATING SYSTEMS PASS FAIL N/A EXITS ASS FAIL N/A ELECTRICAL PASS FAIL N/A FIRE ALARM SYSTEM JPASY FAIL N/A FIRE EXTINGUISHERS PAS FAIL N/A SPRINKLERS TPASS FAIL /A STANDPIPES PASS FAIL N/A EMERGENCY LIGHTS -(PAS§ FAIL N/A KITCHENS f PASS`' FAIL N/A STORAGE PASS FAIL N/A PERMITS YES NO N/A OTHER VIOLATIONS AND COMMENTS REGULAR INSP. QUARTERLY INSP SCHOOL INSP. Form#16(Rev.6/2003) WHITE COPY: FIRE PREVENTION PINK COPY: OWNER r %Zaty of iatem, 'fflaseachusctts 'Fire Pepartinent Meabquartrrs 4$ ?:afnnrftr. litred �c1em, c rz_ 01970 FIRE DRILL REPORT-aNERAL Date: City Alarm Box# Location: d�02 � i '/ Box Plugged Out Name of Occupancy: Plugged In Exact location of drill area: Method of sounding drill alarm: Time of Drill: e�v� , 4 Time to complete evacuation: Time of Recall: "&2 (Do not use Fire Alarm Audible) Nur*ber'of Participating Personnel: c,2 0 Name of person initiating drill: Type of drill: Regular Blocked Exit Were all fire doors closed as required by law? /O d Did any personnel respond with fire extinguishers? Does this occupancy have an organized fire brigade? Did evacuation proceed properly? � Fire Drill Discipline? �6d Weather Conditions Other Reports: Report by: � Signature One copy to be forwarded to:Salem Fire Prevention Bureau 48 Lafayette Street, Salem, Mass. Form :M (1/80) r - e L Ttu Of ,`Ontent, 'Massachusletts Aire LUepartinent Peabquarters unx4. t 48 CafagcttE `street �,�$alem, 749a. 01.970 FIRE DRILL REPORT-=RAL Date: gZ,�,-/ City Alarm Box# Location: 2- 1 a— �]---�-� Box Plugged Out Name of Occupancy: ec�.��- Plugged In Exact location of drill area:' Method of sounding drill alarm: ✓� '� Time of Drill: / Time to complete evacuation: Time of Recall: /�, � 7 /440 (Do not use Fire Alarm Audible) Number of Participating Personnel: �v Nara of person initiating drill: Ce Type of drill: Regular Blocked Exit Were all fire doors closed as required by law? Did any personnel respond with fire extinguishers? Does this occupancy have an organized fire brigade. Did evacuation proceed properly? Fire Drill Discipline? Weather Conditions �� A07 �' Z)/1 Y Other Reports: Report by: Signature One copy to be forwarded to:Salem Fire Prevention Bureau 48 Lafayette Street, Salem, Mass. Form #5B (1/80) . r SALEM FIRE DEPARTMENT INSPECTION AND VIOLATION REPORT DATE: Wo;/-Al STATION: ADDRESS: NAME:/,�,�d A PHONE: BLDG. CLASS: '�4' �j ALARM CO: OFFICER: tc, I F/F: F/F: MULTIPLE BUSINESSES, RETAIL SPACES FICES, TC. OCCUPANCY PHONE# OCCUPANCY PHONE # EXTERIOR OASS AIL N/A HEATING SYSTEMS PASS FAIL N/A EXITS PAS N/A ELECTRICAL PASS FAIL N/A FIRE ALARM SYSTE PASS FAIL N/A FIRE EXTINGUISHE PASS AIL N/A SPRINKLERS PASS FAIL N/ STANDPIPES IPASS FAIL N/A EMERGENCY LIGHTS PAS FAIL N/A KITCHENS PASS FAIL N/A STORAGE PASS ' AIL N/A PERMITS YES O N/A OTHER VIOLATIONS AND COMMENTS 6A Ae e /tP ltf/✓R � 4zg' ., REGULAR INSP. QUARTERLY INSP. SCHOOL INSP. Form#16(Rev.6/2003) WHITE COPY: FIRE PREVENTION PINK COPY: OWNER ;C . SALEM FIRE DEPARTMENT INSPECTION AND VIOLATION REPORT DATE: 0 `"L 0 STATION: L.-2- ADDRESS: 161 F-C Irk NAME: (a rCk r f4,f EA , S(rvir GCt S PHONE: I BLDG. CLASS: ALARM CO: OFFICER: 1_t Ai (1 j6 f- I F/F: f:l,u"(,h i F/F: � aV�iSUv1 MULTIPLE BUSINESSES,RETAIL SPACES,OFFICES,ETC. OCCUPANCY PHONE# OCCUPANCY PHONE # EXTERIOR AS§Z FAIL N/A HEATING SYSTEMS PASS FAIL N/A EXITS PASS FAIL N/A ELECTRICAL PASS) FAIL N/A FIRE ALARM SYSTEM 6 PAS2 FAIL N/A FIRE EXTINGUISHERS tPASV FAIL N/A SPRINKLERS JPASS FAIL /A STANDPIPES TWSS FAIL N/A EMERGENCY LIGHTS PASS FAIL N/A KITCHENS PASS FAIL N/A STORAGE PASS FAIL N/A PERMITS I(YEJ NO N/A OTHER VIOLATIONS AND COMMENTS REGULAR INSP. QUARTERLY INSP. SCHOOL INSP. Form#16(Rev.6/2003) WHITE COPY: FIRE PREVENTION PINK COPY: OWNER I/ t { t ee 1tnn'' is r SALEM FIRE DEPARTMENT � INSPECTION AND VIOLATION REPORT DATE: STATION: ADDRESS: J�: NAME: PHONE:'qV-7V!;--2YV61 BLDG. CLASS: ALARM CO: OFFICER:<f ,� `��� F/F: ��ii r' F/F: �S J:ngsr MULTIPLE BUSINESSES,RETAIL SPACES,OFFICES,ETC. OCCUPANCY PHONE# OCCUPANCY PHONE# EXTERIOR PASS FAIL N/A HEATING SYSTEMS PASS FAIL N/A EXITS ASS FAIL N/A ELECTRICAL PASS FAIL N/A FIRE ALARM SYSTEM PASS FAIL N/A FIRE EXTINGUISHERS 4 PASS FAIL N/A SPRINKLERS IPASS FA N/A STANDPIPES PASS FAIL N/A EMERGENCY LIGHTS I PASV FAIL N/A KITCHENS PASS FAIL N/A STORAGE PASS FAIL N/A PERMITS YES O N/A OTHER VIOLATIONS AND COMMENTS REGULAR INSP. QUARTERLY INSP. SCHOOL INSP. Form#16(Rev.0003) WHITE COPY: FIRE PREVENTION PINK COPY: OWNER 03/12/2007 13:39 9787454809 HES PAGE 01/01 ire, CUTI ICA 1 g o.� SE MMO T' wC,oubmci with the regairments of�Cti ha ,fiCate of luspet=i0n issr�ed by the head of the we'CPtspter I 11, Section 51 this c with l ordina�oes is a er 1 1 Fire Depa Rent oft It pr e�wsite far an odol1 or mnewal license. 9 COMpliance NtWE OF CLINT ADDMS5 OF CL- o for It MOW CERTUY MAT TMs wsmnmv cc mrLw SWI7l3 TM AL ORDINA r-ES. Z.-4— If answer is"No", indicate VdoLlfic s ate recommend4ow. Violations: Itecornt m4atiow. ISSUED BY: „ - Hc eCl�l Firs INS9PR1lriC7'ION: DEPARTfiW" C)1RE'1`s N,IWO COWLETED COPMS ro CLINIC CL NYC'TO kETURN ONE COPY ju Dot ott ublic Health Division of Emith Cara Qmbty 99 Mau=y$tfied Boston,MA, 02111 Rev,I N05-05 03/12/2007 13:39 9787454805 HEM: PAGE 01/01 IN Tin sccord=6 with tho requirements of t metal Laws �tifbate of l�pction issued by the heaat Chapter t I t,.Rewon 51,this Fire with IOeal ordi ®f the local Fire Depart eat C CC is a Prerequisite for an OdOO Oy Mewal lieelzse. ftj�jn� 1 S.�Uj6u NAM OP CMI ADI)Ft`M OF GLRIC wa3 inspected on if DEIEIIY GTA:MY TaAr TMS UgS'rMMON CoMP'LMS WITH TBM LOCAL ORDANAXrF.S. Z YM— NO If answer is`Wo", indicate vi®latiM ObI McOmmendatioes, violations: ItscomAzxe'adations,: ISSUED BY. i H 0t'Jt.ocul F= nt INSTRU+C'I"%ONS: M DVAR,TMENT TO R i1', N'lWo COAo'L1rTED CO ptES ro CLNIC CLINIC'METURN ONE COPY'1 a Dot ofPublic 11cilth Division of XmIth Gam Quality 99 C1muncy S+tt Boston,lA 02111 f COMMONWEALTH OF MASSACHUSETTS ` ^\ DEPARTMENT OF PUBLIC HEALTH HOSPITALS AND AMBULATORY CARE FACILITIES CLINIC QUARTERLY FIRE INSPECTION REPORT IN ACCORDANCE WITH THE REQUIREMENTS OF GENERAL LAWS, CHAPTER 148, SECTION 4, THE MARSHAL OR THE HEAD OF THE FIRE DEPARTMENT, TO WHOM HE MAY DELEGATE AUTHORITY SHALL MAKE AN INSPECTION EVERY THREE MONTHS OF THE INSTITUTIONS LICENSED BY AND UNDER THE SUPERVISION OF THE DEPARTMENT OF PUBLIC HEALTH, SHALL MAKE A REPORT OF SUCH INSPECTION TO THE DEPARTMENT OF PUBLIC HEALTH ON FORMS PROVIDED BY SUCH DEPARTMENT. t IN ACCORDANCE WITH SUCH SATUTORY MANDATE , THE: P� I+h a leGGI ij Name of CLINIC ADDRESS`-OF'CLINIC WAS INSPECTED ON: 1���/� 7 DATE OF INSPECTION j 7 BY: 6)_Q _ Name of inspector Report of inspection: APPROVED DISAPROVED SIGNITURE AND TITLE CC: BUILDING INSPECTOR HEALTH DEPARTMENT CLINIC & FILE f 03/12/2007 13:39 9787454809_ HES PAGE 01/01 . tr. Mon Tj1 accordance with tba requiftmeWs of General Laws �ti&ate of ,Chapter 1 i I t 0u issued by the 12�d Of the Jor Firs D , sftoon 51 this JFire with local ordimmcs is a preregWsite for as odgi�al or mnewalrent cerbifying compliance SAUi6a MA- ADD"SS OF CL IC Was inspectee _ by. �Qe o � g VXREby C>CRWV THAT TWS.IP19'ICMMON C,)MrlXSSWITR nU LOCAL,ORDINANCES. YES—Vz mo If Answer is"N&y indicate violatti om a0 I ftcoaatnendetiow, Violations: Xeco en4atiow- ISSUED BY: sip" He of Jar Fig Fly DEPAR,TMCI NTTO RMMN'IWO CORII LETEO COPIES ro CLINIC CLNIC'TO KETM ONE COPY To. 15wotwW olPublie Health Division of Health Cie( uMrjty Uastoi4 MA 02111 03/12/2007 13:39 9787454809: HE '. PAGE 01/01. sr. T11 sccordance with the � 1if tcate of reQuirernts of Gezleral Lewis,Chapter l l t, cbinn 51 with local ordinate is issued ui the head of the local Fire D this Fire es is a write fo,r as"doiz l or xeraewal license.� ce' fj ing compliaum NA.ML OF CL1Nl, A- AT.DDUSS OP CL Q C was bspectee $13MREDY CCRMY TaAT'rms jNgrMTj0x Co Mr LMS WITB M LOCAL ORDINANCES. YES—AZ NO —,.�.... If answer is"NW, indicate viOlaffioas an i cb�otnend�atioos. Violations. Itecam;ol�4atitm�: r ISSUED BY: He ot'1<.o�1 Fire INSTRUCTIONS: r F11t1x DVARIMENI'TO URN'IWO CoiaLETM)COPIES To CLINIC CLDgC TO RETURN ONE COPY Ta Dot of Public]Hcalth Division of Heam Cm Quality "CbRuncy sleet Boston,MA 02111 Rev.10-05-05 03/12/2007 13:39 9787454809 HES PAGE 01/01M—CAR—TI-XICAIM, op MIN Tia rdazace with the requirenaeWs of Gen Cmli&ate of csat La wm,Chapter I 11, Section 5I this with Iacal ardi tiou issued by the head of the loael Firs D meat _ Fie is a I '�wsite Far an cw oa,or miewal license. Cerlr���campl�� 1 <5ic4 0 Y , MAW Op CLN1 a -SS OF CL C .- was mspectes t IMM CRR7I'W TA.Ti 'tWs IIM"VTj0N CohML S WITH LOCAL CRDINA "S. YES—Z X0 If An wer is"N&r indicate violadons ari I mcomtnendp tip. Violations: Iterorn�e'caatitrns: ISSUED BY: Si He ot'l.oW Fire t IN'STRUC7"fONS: r FW DVARRIfiW TO REMV'IWO CO20LETED COPM3'; o CljNIC CLIMC TO R ET UM ONE COPY Tay: DepArt =t of Public 11c&tb Division of Reelth Cm Qwgity 99 Cha,icy stet $oaten,MA 02111 ltcv,l0.b�-OS ' f 03/12/2007 13:39 9787454809, HES PAGE 01/01. In scmrdance with the reciuirernents of Gm eral Lawn,Cttapter l�t � Cerd ate of 1pcatiou issued by the head of the local Fire D ! Sestina 1,this.Fire with lo�l ordtnauces is a Prerequisite fox an arioa)or ta'ewal liar n.,C. cftlf fig eomplianc" t , h N�m Of CLINI A- ADDUSS OF CL N,, Was insp Cte by ANagm li 13MREW CUTUy THAT TWS 3A STrrMON COMPLMS V4TS TM a,,r XAL OBnWANCES. NO If answer is`. `NO'', tndicale vt0la4,iians aiS I a+ccOMtnendatiocs. Violations: ���1�lA�rltlo315: ISSUED BY: s� - x� INSTRUCTIONS: FW :Y DEPARTMENT TO RMMN'rWo C010LEM Coma TO CLINIC CLINIC TO RETURN ONE COPY ja Dom;of Public Health Division of Xmit a Cane Quality "cbjkulcy ftct Boston,MA 02111 R,cv,i ao.�-as Page. AVAV jr Fire Alarm Test Date/ ��d Report Inspector �f c ven /4,/C tiirtGi� SRUMV Symms spec►snsrs License#Q M Property Tested Owner/ Management @ Named ���, Fr � Name_ U� tt ��1 i14 .�C�t v/'G e.j' Address 1 6 2- FeC t rg� Address CA /Co%vn 7 6qO aaIern . MA AM Phone ( ) Phone (77y ) 23® Contact -T-y-®� Contact Control Panel Id'av Manufacturer z ► en 4- ko 4` Model ao. Zones Panel Volta a yVG Zone Zane pp Location C C Cf 0 Software Rev. Software Date tyie Gass !J Other Info) r-ea. ker rr CT I Gr h(0 Gin t.ou id to csT iv*--e,C.e. r-C'k�,- .i{.a 2. -t'-. Mgr C c Breaker Lock Dedicated Mr. Breaker Location Number Yes ❑ No ❑ Yes ❑ No ❑ Local Masterbox Standard n Radio El I Fire Department -tea 1 e-r•, Phone# P9 7yy12-,s'S— Central Station 16 1 Box-Account#60 2 -.5-Wl Monftored By A-S+tt hT ct r Phone#97 -7 y 9©7 o Fire deplXenlml I Ham Ham Pass Code Received Signal Yes ❑ No ❑ r4q. class Batteries �- Pass ❑ Fail ❑ Replaced ❑ Voltage Amp/Hour -7. 0 Knox Box Yes No ❑ �'Upon arrival panel was: Normal IV In Trouble ❑ in Alarm ❑ Dead ❑ What was In trouble What was In alarm Physical condition of panel Good W Other Auailary Device Type of Exterior NotificaUon& Location O ir-m f ! -+r o l f e Sr)`dle Annuclator& Loo. Q I A Elevator Recall j Primay Yes ❑ No Id I Seconds Yes ❑ No lL/1 Dampers Yes No I� L131nf Test Yes No Drill Sw Yes No El Remote Reset Yes 11 No 21 Remote Ack. Yes U No lit I no orn Supplies Yes No Loc. Vo a Am our Loc. Voltage Amp/Hour Loc. Voltage Am our Volta a Am our Sveclal Considerations-Llst any unique function to be aware of before testing 1. u 5T c. 1 i Fi're- .4R 7- e v e-n a,- ' s f`S I mo+' fri r 2. f( Sid s Signature Time Date ACP Corp. Security and Fire Systems P.O. Box 3065 Woburn Ma. 01888 Ph. 1-800-285-3235 ® ® Name Page - of AV Address pate 3 f 2 17 SWIMV symms S0001, 919 Device Floor-Area Location of Device Pass Fail Repair0 e/ C',r lam/ -,54o irtve/I 51 3 1 S'+q 1 r,,,e ( ( i• 3 S at'r e(( ek,`f }-1 S 3 ('rw e (I N 3 4 3oq ! 3 n 4- 3cs 1-1 3 3 c)-7 3 3 312 e-k°I-er�or 3 i S' Z 2 Z :3 ek 4-9,n`0-Y- H S 7- p z 14 2 5! Lacer anP�� K.S -ram e�,�+ FSmoke Detector HS =HomlStrobe C =Control Module DH =Door Holders Heat Detector HO =Hom Only M =Monitor Module DM =Damper Duck Smoke Detector B =F_xtedor Notification PS=Aux Power Suppy FP =Fire Phone Pull Station ST =Strobe Only T =Sprinkler Tamper Switch O =Other110v Smoke Detector ML =Masterbox Light F =Sprinkler Flow Switch BA =Batteries BM=Beam Detector MH =Nrml Hom Ann=Annuciator Co=Corbon Monoxide BL -Bell Only ACP core. Security and Fire Systems P.O. Box 3065 Woburn Ma. 01888 Ph: 1-800-285-3235 ® Name Page 3 of AF in Address to Z red-p�u S-f- Date 3 f 2- 91 —7 . .S"4 MA 9@UUnV 4MON 0=11 50 Device Floor-Area Location of Device Pass Fail Repair[] 2 Zz3 ek- ei,`cr 4 V n 2.l b S z- 2- I < �5 W 420Y-1^ CPc�- P f Vel f'f cie S ex(e,-4,>" f `7 8 e x P (3 ek,,4 I`t 5 13 �k r S =Smoke Detector HS =HomlStrobe C =Control Module DH =Door Holders H =Heat Detector HO =Hom Only M =Monitor Module DM =Damper D =Duck Smoke Detector B =Exterior Notification PS=Aux Power Suppy FP -Fire Phone P =Pull Station ST =Strobe Only T =Sprinkler Tamper Switch O =Other 31 =11 Ov Smoke Detector ML =Masterbox Light F =Sprinkler Flow Switch BA =Batteries BM=Beam Detector MH =Minl Hom Ann=Annuciator CO=Corbon Monoxide BL -Bell Only ACP core. Security and Fire Systems P.O. Box 3065 Woburn Ma. 01888 Ph. 1-800-285-3235 ® ® Name Page Of Address 6 ( S+ Date S/ 2 E)1-7 SeauNql Sr/slbms Spec/a/Isla Device Floor-Area Location of Device Pass Fail Repair0 S s�a�- K fit.,. Frar� 6/w/ Id S =Smoke Detector HS =HomlStrobe C =Control Module DH =Door Holders H =Heat Detector HO =Hom Only M =Monitor Module DM =Damper D =Duck Smoke Detector B =Exterior Notification PS=Aux Power Suppy FP =Fire Phone P =Pull Station ST =Strobe Only T =Sprinkler Tamper Switch O =Other Si =I iov Smoke Detector ML =Masterbox Light F =Sprinkler Flow Switch BA =Batteries BM=Beam Detector MH =Mmi Horn Ann=Annuciator C0=Corbon Monoxide BL -Bell Only ACP core. Security and Fire Systems P.O. Box 3065 Woburn Ma. 01888 Ph. 1-800-285-3235 I i j,7 ® Name Page ofAddress � ra S-f- Z�?- Date 3 / 7 $Mwft SWOMS spov"M A Fire System test report correction sheet Problems/ Corrections/ Upgrades needed to system znJ floo-, Q 2 M-0�(,Q,5 List reasons for above,corrections to U — v n r,o Y a m ` o,r, � �'►•� — s k� s� Q,�- i`�s c, c� b ! �a� � all �a ACP core. Security and Fire Systems P.O. Box 3066 Wobum Ma. 01888 Ph. 1-800-285-3235 Uor�i'ly G� �l Hor�na a, Tyr 4�10 C17 7f) 7 s, �,ro ; . i 1' I Fr a i. le tv Mill =yS{ 3 "fi sY S gw -- Aye b 3,y} s R ,c7l- }ice. � jai '4+:r �i.B'U: - I J , 'EOh i IN •��,�YL � ' "�9 �° ]tij `5 �1 `�9'* �t� �"' W. ik. A. uskw 0 . m ENUINE;XL.gagfrorr� girder or�fy�G. z _ > rdealar d�str�butor or � w ��,�_� � F se � a , x � � ta 1800 2 ROaD NTATION1 `{ tOOF'k.AISIAN�x9 . OR�EANS�'LOP � � ¢ry - BAGNUMBER MCV �2 IN 41 ro �*3.�'s� � �� ,z � ��t�< �� •�` 'ram p + I fi 4 g . n 7, 05/24/2006 16:06 9787457615 H PAGE 02/02 HEALTH AND EDUCATION SERVICES,INC. FIRE DRILL COMPLETION FORM Be it knowrn that a fire drill was held at Health and Education Services,]nc.at (Address) s (Date-montlVdaylyew) Time of Drill: J Time needed for evacuation: 1 M-t Personnel accounted for: Yes No Names of participants in this drill mease write names below or attach a list): Comments: Signature: Date:- (Fire Department Representative) Si iafore: ® Date: (Site Director and/or Maintenance Personnel) File original with H ES Safety Officer File copy on site Ppl-5FireSafety.doc Page 3 of 3 02004 Health 8c Education Servtces,Inc. 05/24/20.06 16:06 9787457615 H PAGE 01/02 Health & Education Services. Inc. rto. Lieutenant Griffin From: Florence Williams Fax; 978 745-9402 Pages: 1 Phone; Date: 5/25I2006 Re: Fire Drill CC: ❑ursent OFor Review O Please Comment ©Please Reply O Please Recycle •Comments:, Hi Lt. Griffin, Thank you for helping to schedule a fire drill for the address below. A copy of a Fire Drill (:;ompletion form follows this page. I look forward to talking with you or your colleague regarding a date and time for the drill. . Thank you, Florence Williams Office Manager Salem HFS 162 Federal Street Salem MA (978) 745-2440 x 202 Fax (978) 745-4809 STATEMENT of ct}NFIDENNALITY The documents included with this facsimile cover shoot contain informadpa from HES,Inc.which is cotlydentlal and/or pn'i f.-ged. This Wornnation is Intended m be for the use of the addressee named on this fransmlttal sheet N you are not the addressee,m to-that any disclosure,photocopying,distribuVon,Or use of the contents of faxed Information is prohibited, if you have received this fw.-J rife in error, please notify us by telephone(collect ifneceswy)immediately, City of Salem, Massachusetts .dire Department � yR 48 Lafayette Street Robert`IN.(Turner Safem, Massachusetts 01370-3655 Fire Prevention Chief TeL 978-744-1235 Bureau 978-744-6990 FaX 978-745-4646 978-745-7777 FIRE DRILL REPORT-GENERAL DATE: CITY MASTER BOX# LOCATION: BOX PLUGGED OUT (Y) (N) NAME OF OCCUPANCY: EXACT LOCATION OF DRILL AREA: METHOD OF .SOUNDING DRILL ALARM TIME OF. DRILL: TIME 'TO,'CONPLET-E EVACUATION: �. .' . TIME OF RECALL: _NUMBER'OF PARTICIPATING PERSONNEL: NAME OF PERSON INITIATING DRILL: TYPE OF DRILL: REGULAR BLOCKED EXIT WERE ALL FIRE DOORS CLOSED AS REQUIRED BY LAW? DID ANY PERSONNEL RESPOND WITH FIRE EXTINQUISHERS? DOES THIS OCCUPANCY HAVE AN ORGANIZED FIRE BRIGADE? DID EVACUATION PROCEED PROPERLY? FIRE DRILL ,DISCIPLINE? WEATHER CONDITION: OTHER REPORTS: FORM#5B 4/2002 REPORT BY: Signature & Title I a %Uitv Of ateral U635ac tuadhi 4H Aire Departinent Peubquarters aaxf. 48 fagrttr �$frert Lem, cAla. 01,970 FIRE DRILL REPORT-=RAL` Date: January 31, 2007 City Alarm Box# Central Station Location: 162 Federal Street Box Plugged Out Name of Occupancy: Health & Education Services Plugged In Exact location of drill area: e ,.`; � .. ^4t,n Method of sounding 'drill alarm: Nkl' iAA c4, Time of Drill: J Time to complete evacuation: '� O Time of Recall: (Do not use Fire Alarm Audible) Number of Participating Personnel: Nam of person initiating drill: Lt. Griffin t4 Type of drill: Regular xxxxx Blocked Exit Were all fire doors closed as required by law? -- Did any personnel respond with fire extinguishers? Does this occupancy have an organized fire brigade? NO Did evacuation proceed properly? y C,A Fire Drill Discipline? t` v-tQ v� Weather Conditions Other Reports: Report by: One cony to be forwarded to:Salem Fire Prevention Bureau 48 Lafayette Street, Salem, Mass. Form #SB (1/80) 4.4r C . sa o (ems, assachusetis � ,� Fire Departrnent 0 48 Lafayette Street David Cody Salem, )qtassachusetts 01970-3695 Fire Prevention Chv Te( 978-744-1235 Bureau 978-744-6990 Fax 978-745-4646 978-745-7777 do odyClsa(zm.com March 30, 2006 Dear Business Owner/Manager Enclosed is your Annual Permit Renewal Notice. If the Primary Contact Information on the Permit ene al Notice is highlighted please write in the name, address and phone number for 24nty- ,ur hour emergency contact person so as we may update our files. If t e ary'CcMct Information is filled in please verify that the info. atio 's curre t. 0 (� a if u ave any question�ss, , eo assis - c e ca`il�he Fire Prevention Office at ( '7.8) 7 -7777. 0 Than10you in advance for your anticipated co-operation. Salem Fire Department Fire Prevention Divisio 0 0 0 ii f a Qlltv of "Salem, assay autts Aire Department �ieabquarterz 48 ?1afagettr. $treet ��1em, c�tt. II�a7II FIRE DRILL REPORT-GENERAL Date:— January 31, 2007 City Alarm Box# Central Station Location: 162 Federal Street Box Plugged Out Name of Occupancy: Health & Education Services Plugged In Exact location of drill area: Method of sounding drill alarm: Time of Drill: Time to complete evacuation: Titre of Recall: (Co not use Fire Alarm Audible) Nur.•ber of Participating Personnel: Name of person initiating drill: Lt. Griffin Type of drill: Regular xxxxx Blocked Exit Were all fire doors closed as required by law? Did any personnel respond with fire extinguishers? Does this occupancy have an organized fire brigade? NO Did evacuation proceed properly? Fire Drill Discipline? Weather Conditions Other Reports: Report by: Signature One copy to be forwarded to:Salem Fire Prevention Bureau 48 Lafayette Street, Salem, Mass`: Form #5B (1/80) SALEM FIRE DEPARTMENT - In . �Dake: Insp� Nu03 mberINSPECTION AND VIOLATION REPORT Rei p. ate: Occu ancy me Occ p cy T e �c t L• Addre s Bldg.#'s Floor/Section plop e E • t , r,� St Yes No El `1 r� 74S'X� In p ctor.Name Comp ny# Notifications L tom-' d — ❑ Health ❑Bldg. ❑Electrical ❑Police 1. Exterior 6. Heating Systems ❑ N/A fire escapes/decks ❑ Pass ❑ Fail ❑Warn ❑ N/A combustibles Pass El Fail ❑Warn El N/A proper storage Pass El Fail El Warn El N/A within 5 feet ,` proper access Pass ❑ Fail ❑Warn ❑ N/A defective chimney bd Pass ❑ Fail ❑Warn ❑ N/A KNOX BOX Pass ❑ Fail ❑Warn ❑ N/A defective system L1 Pass ❑ Fail ❑Warn ❑ N/A 2. Exits other b Pass ElFail ElWarn ElN/A open properly Pass ❑ Fail ❑Warn ❑ N/A 7. Electrical exit blocked Pass ❑ Fail ❑Warn ❑ N/A defective wiring )(Pass ❑ Fail ❑Warn ❑ N/A exit signs working Pass ❑ Fail ❑Warn ❑ N/A panels accessible Pass ❑ Fail ❑Warn ❑ N/A adequate lighting Pass ❑ Fail ❑Warn ❑ N/A extension cords: door(s)locked Pass El Fail El Warn ❑ N/A proper use Pass ❑ Fail ❑Warn ❑ N/A signs needed f� Pass ❑ Fail ❑Warn ❑ N/A cover plate missing Pass ❑ Fail ❑Warn ❑ N/A in need of repair Pass ❑ Fail ❑Warn ❑ N/A proper fusing `1 Pass ❑ Fail ❑Warn ❑ N/A emergency lights Pass ❑ Fail Warn ❑ N/A other ❑ Pass ❑ Fail ❑Warn ❑ N/A other Pass ❑ Fail Warn ❑ N/A 8. Fire Extinguishers ❑ N/A 3. Fire Alarm System El N/A signs needed Pass El Fail El Warn El N/A operative Pass El Fail El Warn ❑ N/A properly mounted Pass El Fail ❑Warn El N/A properly labeled Pass El Fail El Warn El N/A proper type Pass El Fail El Warn ❑ N/A accessible Pass El Fail El Warn El N/A obstructed `�] Pass El Fail ❑Warn ❑ N/A trouble indication Pass El Fail El Warn El N/A need recharging �Pass El Fail El Warn El N/A defective devices ass . El Fail El Warn El N/A other Pass El Fail El Warn ❑ N/A • missing devices Pass ❑ Fail ❑Warn El other Pass ❑ Fail ❑Warn ❑ N/A 9. Sprinkler & Standpipe System 4. Kitchens X N/A 10 lb.ABC extinguisher ❑ Pass ❑ Fail ❑Warn r /A . valves labeled ElPass ❑ Fail ElWarn ElN/A at hazard valves accessible ❑ Pass ❑ Fail ❑Warn ❑ N/A ext.system operat. ❑ Pass ❑ Fail ❑Warn 1�N/A pressure reading ❑ Pass ❑ Fail ❑Warn ❑ N/A roof collect.clean ❑ Pass ❑ Fail ❑Warn N/A FDC clear/capped ElPass ElFail ElWarn ElN/A system inspected ElPass ❑ Fail ElWarn N/A valves open ❑ Pass ❑ Fail ❑Warn ❑ N/A hood/duct clean ❑ Pass ❑ Fail ❑Warn ❑ N/A valves secured ❑ Pass ❑ Fail ❑Warn ❑ N/A other ❑ Pass ❑ Fail ❑Warn ❑ N/A spare head avail. ❑ Pass ❑ Fail ❑Warn ❑ N/A heads obstructed ❑ Pass ❑ Fail ❑Warn ❑ N/A 5. Storage other ❑ Pass ❑ Fail ❑Warn ❑ N/A e proper labeling Pass ❑ Fail ❑Warn ❑ N/A proper storage M Pass ❑ Fail ❑ Warn ❑ N/A PTN Form#84-Completed Yes❑ No ❑ legal storage Pass ❑ Fail ❑Warn ❑ N/A Form#58-Filed Yes ❑ No❑ other Pass ❑ Fail ❑Warn ❑ N/A 10. Violations Found Form#16-(Rev.11/93) Copies: White-Fire Prevention Yellow-Inspecting Company Pink,=Building Owner/Manager Ref.Ne:G 104502373 COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH HOSPITALS AND AMBULATORY CARE FACILITIES CLINIC QUARTERLY FIRE INSPECTION REPORT IN ACCORDANCE WITH THE REQUIREMENTS OF GENERAL LAWS, CHAPTER 148, SECTION 4, THE MARSHAL OR THE HEAD OF THE FIRE DEPARTMENT, TO WHOM HE MAY DELEGATE AUTHORITY SHALL MAKE AN INSPECTION EVERY THREE MONTHS OF THE INSTITUTIONS LICENSED BY AND UNDER THE SUPERVISION OF THE DEPARTMENT OF PUBLIC HEALTH, SHALL MAKE A REPORT OF SUCH INSPECTION TO THE DEPARTMENT OF PUBLIC HEALTH ON FORMS PROVIDED BY SUCH DEPARTMENT. IN ACCORDANCE WITH SUCH SATUTORY MANDATE , THE: • . HEALTH & EDUCATION SERVICES Name of CLINIC 162 FEDERAL STREET SALEM, MA. 01970 ADDRESS OF CLINIC WAS INSPECTED ON: 5%2/,2060 . DATE OF INSPECTION BY: FIRE INSPECTOR FRANK PRECZEWSKI Name of inspector Report of inspection: APPROVED DISAPROVED SIGNI RE AND TITIA CC: BUILDING INSPECTOR HEALTH DEPARTMENT • CLINIC & FILE FIRE CIR2'IFIaM OF INSPEX.TION In accordance with the requirements of General Laws, Chapter 111, Section 51, this Fire Certificate of Inspection issued by the dead of the local Fire Department certifying ccupliance with local ordinances is a prerequisite for an original or renewal license. Health & Education Services NAME OF CLINIC 162 Federal Street ADDRESS OF CLINIC was 'irlspected on t 6-/5/D7- Lt. Griffin DATE NAME OF OF INSPECIM I HEREBY CFFRZM THAT THIS INSTI=CN CALIFS WItH TM LOCAL CPDDMNM. YES NO If answer r is "NO", indicate violations and recommendations. violations: Reoormeridations: ISSUED BY. E Sic�tia Head of Local Fire Department INSIRdJC'IrtONS: FIRE DEPT. TO PMU N TWO CCMM= CDPIES TO CLINIC CLINIC TO REIVFN ONE OOPY TO: Division of Health Care Quality 10 West Street - 5th Floor Bostcn, MA 02111 FTRE.1 DPHCQ117 . SALEM FIRE DEPARTMENT Inspec. ate: wpjo Insp.Number INSPECTION AND VIOLATION REPORT i Reinsp.Date: • Occupancy Name i I Occupancy Type 1 Address Bldg. Vs Floor/Section Phone Yes No❑ Inspector Name Company# Notlficatio s ❑Health ❑Bldg. ❑Electrical ❑Police 1. Exterior 6. He ting Systems ❑ N/A fire escapes/decks Pass ❑Fail ❑Warn ❑N/A combustibles Pass ❑ Fail ❑Warn ❑ N/A proper storage Pass ❑ Fail ❑Warn ❑ N/A within 5 feet proper access Pass ❑ Fail ❑Warn ❑ N/A defective chimney Pass ❑ Fail ❑Warn ❑ N/A KNOX BOX Pass ❑ Fail ❑Warn ❑ N/A defective system Pass ❑ Fail ❑Warn ❑ N/A 2. Exits other Pass ❑ Fail ❑Warn ❑ N/A open property Pass ❑ Fail ❑Warn ❑ N/A 7. Electrical exit blocked Pass ❑ Fail ❑Warn ❑ N/A defective wiring I i I Pass ❑ Fail ❑Warn ❑ N/A exit signs working Pass ❑ Fail ❑Warn ❑ N/A panels accessible I I Pass ❑ Fail ❑Warn ❑ N/A adequate lighting Pass ❑ Fail ❑Warn ❑ N/A extension cords: door(s)locked Pass ❑ Fail ❑Warn ❑ N/A proper use I I Pass ❑ Fail ❑Warn ❑ N/A signs needed Pass ❑ Fail ❑Warn ❑ N/A cover plate missing Pass ❑ Fail ❑Warn ❑ N/A in need of repair Pass ❑ Fail ❑Warn ❑ N/A proper fusing Pass ❑ Fail ❑Warn ❑ N/A emergency lights Pass ❑ Fail ❑Warn ❑ N/A other Pass ❑ Fail ❑Warn ❑ N/A other ❑ Pass ❑ Fail ❑Warn ❑ N/A 8. Fire Extinguishers ❑ N/A 3. Fire Alarm System ❑ N/A signs needed Pass ❑ Fail ❑Warn ❑ N/A operative Pass ❑ Fail ❑Warn ❑ N/A properly mounted Pass ❑ Fail ❑Warn ❑ N/A properly labeled Pass ❑ Fail ❑Warn ❑ N/A proper type Pass ❑ Fail ❑Warn ❑ N/A accessible Pass ❑ Fail ❑Warn ❑ N/A obstructed Pass ❑ Fail ❑Warn ❑ N/A • trouble indication Pass ❑ Fail ❑Warn ❑ N/A need recharging Pass ❑ Fail ❑Warn ❑ N/A defective devices Pass ❑ Fail ❑Warn ❑ N/A other Pass ❑ Fail ❑Warn ❑ N/A missing devices Pass ❑Fail ❑Warn ❑ N/A other I Pass ❑ Fail ❑Warn ❑ N/A 9. Sprinkler&Standpipe System 4. Kitchens N/A valves tabled ❑ Pass ❑ Fail ElWar ❑ N/A 10 lb.ABC extinguisher ❑ Pass ❑ Fail ❑Warn N/A valves accessible ❑ Pass ❑ Fail ❑Warn ❑ N/A at hazard pressure reading ❑ Pass ❑ Fail ❑Warn ❑ N/A ext. system operat. ❑ Pass ❑ Fail ❑Warn N/A FDC clear/capped ❑ Pass ❑ Fail ❑Warn ❑ N/A roof collect.clean ❑ Pass ❑Fail ❑Warn N/A Valves open ❑ Pass ❑ Fail ❑Warn ❑ N/A system inspected ❑ Pass ❑ Fail ❑Warn N/A valves secured ❑ Pass ❑ Fail ❑Warn ❑ N/A hood/duct clean ❑ Pass ❑Fail ❑Warn N/A spare head avail. ❑ Pass ❑ Fail ❑Warn ❑ N/A other ❑ Pass ❑ Fail ❑Warn N/A heads obstructed ❑ Pass ❑ Fail ❑Warn ❑ N/A S. Storage other ❑ Pass ❑ Fail ❑Warn ❑ N/A proper labeling Pass ❑ Fail ❑Warn ❑ N/A proper storage Pass ❑ Fail ❑Warn ❑N/A PTN Form*84-Completed Yes❑ No❑ legal storage Pass ❑ Fail ❑Warn ❑ N/A other Pass ❑ Fail ❑Warn ❑ N/A Form *58-Filed Yes❑ No❑ 10. Violations Found • Form*16-(Rev.11/93) Copies: White-Fire Prevention Yellow-Inspecting Company mink-Building Owner/Manager 4� �. t .-..T-...,.�.'^"^^. r^•^....•..w.,,•,,r,.+..w✓^v4++.... �,--..+1^"i'•'wt'y: r SALEM FIRE DEPARTMENT';, nspec. ate: Insp.Number � `INSPECTION ANb.VIOLATION REPORT Reinsp.Date: ;, • Occupancy Name -'' L.�i g�S Occupancy Type Address ( Bldg. Vs. Floor/Section Phone t0 Yes No❑ Inspector Name Company# Notificatio s 1 O Health 4 Bldg. ❑Electrical.. ❑Police ...;�! �:� 1. Exterior }° 6. He11Pass ing Systems ❑ N/A fire escapes/decks Pass ❑Fail ❑Warn ❑ N/A combustibles Pass ❑ Fail ❑Warn ❑ N/A proper storage Pass ❑ Fail ❑Warn ❑ N/A within 5 feetproper access Pass ❑ Fail ❑Warn ❑ N/A defective chimney Pass ❑ Fail ❑Warn ❑ N/A KNOXBOX Pass ❑ Fail ❑Warn `❑ N/A defective system Pass. ❑ Fail ❑Warn ❑ N/A other ❑ Fail ❑Warn ❑ N/A 2. Exits open property Pass ❑ Fail- ❑Warn ❑ N/A. 7.� Electrical exit blocked Pass ❑ Fail ❑Warn ❑ N/A defective wiring I I Pass ❑ Fail ❑Warn ❑ N/A exit signs working Pass . ❑ Fail ❑Warn ❑ N/A panels accessible I Pass ❑ Fail ❑Warn ❑ N/A adequate lighting Pass ❑ Fail ❑Warn ❑ N/A extension cords: door(s)locked Pass ❑ Fail ❑Warn ❑ N/A proper use I I Pass ❑.Fail ❑Warn ❑ N/A signs needed Pass ❑ Fail ❑Warn ❑ N/A cover plate missing C I Pass ❑ Fail ,,-p Warn ❑ N/A in need of repair Pass ❑ Fail ❑Warn b N/A proper fusing Pass ❑ Fail ❑Warn ❑ N/A emergency lights Pass ❑ Fail ❑Warn ❑ N/A other Pass ❑ Fail. ❑Warn ❑ N/A other ❑ Pass O Fail ❑Warn ❑ N/A 8. Fire Extinguishers ❑ N/A 3. Fire Alarm System ❑ N/A signs needed Pass ❑ Fail ❑Warn ❑ N/A operative Pass ❑ Fail O Warn ❑ N/A properly mounted Pass ❑ Fail ❑Warn' ❑ N/A _ properly labeled Pass ❑ Fail ❑Warn ❑ N/A proper type Pass ❑ Fail ❑Warn ❑ N/A accessible Pass ❑Fail ❑Warn ❑ N/A obstructed Pass ❑ Fail ❑Warn ❑ N/A trouble indication Pass ❑ Fail ❑Warn ❑ N/A need recharging Pass ❑ Fail ❑Warn ❑ N/A defective devices Pass ❑ Fail ❑Warn ❑ N/A other Pass ❑ Fail ❑Warn ❑ N/A missing devices Pass ❑ Fail ❑Warn ❑ N/A other Pass ❑ Fail ❑Warn ❑ NIA 9. Sprinkler&Standpipe System " N/A 4. Kitchens valves labled ❑ Pass ❑ Fail ❑War ❑ N/A 10 lb.ABC extinguisher ❑ Pass ❑ Fail ❑Warn N/A valves accessible ❑ Pass ❑ Fail ❑Warn 0 N/A at hazard pressure reading ❑ Pass ❑ Fail ❑Warn ❑ N/A ext.system operat. ❑ Pass ❑ Fail 0 Warn N/A FDC clear/capped ❑ Pass ❑ Fail ❑Warn ❑ NIA roof collect.clean ❑ Pass O Fail O Warn N/A Valves open ❑ Pass ❑ Fail ❑Warn' ❑�N/A system inspected ❑ Pass ❑ Fail 0 Warn N/A valves secured ❑ Pass ❑ Fail ❑Warn p N/A hood/duct clean ❑ Pass ❑ Fail ❑Warn N/A spare head avail O Pass ❑ Fail ❑Warn 4 O N/A other ❑ Pass ❑ Fail ❑Warn N/A heads obstructed ❑ Pass ❑ Fail ❑Warn:' ❑ N/A ,. S. Storage other xg ❑ Pass El Fail ❑Warn ❑ N/A proper labeling ; Pass ❑ Fail ❑Warn ❑ N/A r proper storage Pass ❑Fail ❑Warn ❑ N/A PTN Form *84-Completed Yes'❑ No❑ legal storage Pass ❑ Fail ❑Warn 04N/A other Pass ❑ Fail ❑Warn. ❑ N/A Form *58= Filed Yes❑ No❑ Violat'ons Found , ^M Form*16-(Rev.11/93) Copies: White-Fire Prevention Yellow.-Inspecting Company<�`Pink,=Bullding Owner/Manager . i SALEM FIRE DEPARTMENT INSPECTION AND VIOLATION REPORT DATE: 6 d G STATION: ADDRESS: J NAME: PHONE: BLDG. CLASS: ALARM CO: OFFICER: I F/F: l ---r"mAo- MULTIPLE RINTNPRgES, RETAIL SPACES,OFFICES,ETC. OCCUPANCY PHONE# OCCUPANCY PHONE # EXTERIOR PASS FAIL N/A HEATING SYSTEMS PASS tAIL N/A EXITS 4 PASS FAIL N/A ELECTRICAL PASS FAIL N/A FIRE ALARM SYSTEM PASS FAIL N/A FIRE EXTINGUISHERS PASS FAIL N/A SPRINKLERS JPASS FAIL N/A I STANDPIPES PASS FAIL N/A EMERGENCY LIGHTS ASS FAIL N/A KITCHENS PASS FAIL N/A STORAGE PASS FAIL N/A PERMITS YES NO N/A OTHER VIOLATIONS AND COMMENTS REGULAR INSP. QUARTERLY INSP. SCHOOL INSP. Forth#16(Rev.6/2003) WHITE COPY: FIRE PREVENTION PINK COPY: OWNER Cpo�tinzanuse�t� ��¢o�tuae�a 1 erg. . ?'�Ica�rtixt rt°� arc Sacu�cca - t �iec od ek State ;?M NZWAd Fam F429t RECEIPT OF DISPOSAL OF UNDERGROUND STEEL STORAGE TANK NAME AND ADDRESS OF APPROVED TANK YARD Turner Inc. 225 vommesdad St. Lynn, MA 01905 APPROVED TANK YARD NO. N" Tank Yard Ledger 502 CMR 3.03(4)Number I certify under penalty of law I have personally,examined the underground steel storage tank delivered to this'approved tank yard*by firm,corporation or partnership and accepted same in conformance with Massachusetts Fire Prevention Regulation 502 CMR 3.00 Provisions for Approving Unde round Steel Storage Tank dismantling yards. A valid permit was issued by LOCAL Head of Fire Department. FDIDS_a C\ EL _ti to transport this tank to this yard. Name and offtial title Of approved tank yard owner or owners authorized representative: SIGNATURE `m' TITLE DATE SIGNED This signed receipt of disposal must be returned to the local head of the fire artment FDID# pursuant to 502 CMR 3.00. EACH TANK MUST HAVE A RECEIPT OF DISPOSAL TANK.,DA T_A / TANK REMOVE4 FROM Gallon: ! 000 C N Preview Contentt (No.and Save) Diameter Length ,` y) ( horTo") Date Received Fire Department Permit N Serial 0(if avall") Tank LD.#(Form FF-290) Owner/Operator to mail revised copy of Notification Form(FP290,or F7290R)to : UST Compliance, Office of the State Fire Marshal,P.O. Box 1025 State Road,Stow, MA 01775. �CJ�1 tPl DVS. FILE COPY Make application to local Fire Department. Fire Department retains original applieat'son and issues duplicate as Permit. %ow�- etc C1.,&0aOlzz� S� ca- �wve � �. AO APPLCa'10 Mad PE IT for s.t nk removal and transportation to approved tank disposal yard.to accordance with the provisions t1 � ter 14 , ectioD W. 527 CxirlFl 9.00, appiiCatlott.is_Mrrret +r1,ar by:lot Tank Owner Mama(please print) _;7_�r.�r �'N�/ -�'�aZ X r ro,a• wit . : .. ......:..:. _..: .. ...._ ICornpanY14,4 I'te; na ,n� �- /,1�i .re "ram__ Co.or Individual - — - - PY" air Address <_m' LcJ4 ¢ Addro s SiortatuFe.(if 5 yitag:fer permit) �''� (p�� ' �`�0 } Signature(K applying for pertnN) .: i I C) (FC tertifted tier . ICI Certified t7 LSP# Other i Tank L6.. s`1ibh---.rG v ails)' re,s CRY Tank C40Aq.N.(*&jl0h;sj�- ,�� �n Substance Last Stored Tank Dimensions( iameter x length) Rerntirks: Shall measure for presence ofecontaminants. , All. documentation shall be forwarded to this office, -i.e. any copies of remediation. lisle rlR`F•'tl F " frsBitSYrHif5j bctii+Y 'GV C� am rn n « e,�//�{ J��J� Z'Va State Lic.# _�a Hazardous waste manifest# E RX# h;7�!j 010 by C:'-92 7 ef' Approved tank disposal yard ur p c �^u �Tank yard# 0 6:4 Type of.inert gas C �� Tank yarn eddress C�:�c em�Uf -�'1 d 7torio" YFUID# ermit# .-Date of expiration Dig sate approval number.4zt e- JZ ' _ Dig Safe Toll Free Tel.Plumber•800-322-4844� Signature/Title of Cfficer granting permit Afler removal(s)send Form FP-290R signed by I-ocal Fire Dept.to UST Regulatory Compliance Unit.One.Ashburton Place, Room 1310,Boston.MA 02108-1618. 2-d 8066-i'a - T8L '0WI `NWHI_ H1­1a3MW0WW00 eLT s I T LO a0 2nH , 'A?,7rr%rr1d,/-d/ Notification for Removal or Closure of In Place Storage Tanks Regulates! Under 527 CMR 9.00 Forward completed form,signed by local fire department,to:Mass. UST Compliance Unit, _ ,- _ • Dept. of Fire Services, P.O. Box 1025-State Road, Stow, MA 01775 1 Telephone (978) 567-3710 * Date Received: C� N, Fire Dept. ID# d (Fire Department retains one copy of FP-290R) Fire Dept. Sig. This form is to be used for notification for removal of Underground Storage Tanks/ Piping. If a storage facility has UST's which are to remain in use, an entire amended FP-290 A. Facility Number (long form) must be filed. B. Date Entered Note: "Facility street address"must include both a street number and a street name. C. Clerk's Initials Post office box numbers are not acceptable, and will cause a registration to be D. Comments returned. If geographic location of facility is not provided, please indicate distance and direction from closest intersection, e.g., (facility at 199 North Street is located) 400 yards southeast of Commons Road (intersection). 1. OWNERSHIP OF TANKS) 11. LOCAT'ION OF TANKS, Owner Name(Corporation,Individual,Public Agency,or Other Entity) If known,give the geographic location of tanks by degrees,minutes,an( seconds.Example:Lat.42,36, 12 N Long.85,24. 17W J j_� � 1 - Latitude Longitude lqe-c.yl� �r r��, .t�ca_ld � a'1 \ .ire A f�.•1 Street Address Distance and direction from closest intersection(see note above) ®� !w CC 7110 " _ Facility Name or Company Site identilier,as applicable d g City �'-d Slate Zip ode avee�7+ddresr,tP--_aox.00t.accepiabte�cow-abov counly City - state Z,p Code Phone Number(include Area Code) Owner's Employer Federal to rr County M. TANKS/PIPING REMOVED OR FILLED IN PLACE Tank Number Tank No. ff _ Tank No. Tank No. Tank No. Tank No._ 1. Tank/Piping removed or filled in place (mark all that apply) A. Substance last stored 14 F __j I B. Tank capacity gallons /aaft C. Estimated date last used (mo./day/yr.) sJ6v ——————— ————— ———— D. Estimated date of removal (mo./day/yr.) d t-1 D 7 E. Tank was removed from ground I Ues 1. J F. Tank was not removed from ground Tank was filled with inert material I---i Describe material used: t-- G.Piping was removed from ground ''es H.Piping was not removed from ground I. Other, please specify FP-290R(revised 5/98) O\ 2. Tank closed in accordance with 527 CMR 9.00 es No Yes No Yes No Yes No Yes t A. Evidence of leak detected ves No Yes No Yes No Yes No Yes r B. Mass. DEP notified _ Yes No 'Yes No Yes No Yes No Yes t` 1. Mass. DEP tracking number d3 f 2. Agency or company performing` contamination assessment' ' `527 CMR 9.07(J),see"Commonwealth of Massachusetts,Underground Storage Tank Closure Assessment Manual"April 9, 1996 DEP Policy#WSC-402-96 I declare under penalty of perjury that I have personally examined and am familiar with the information submitted in this an all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the inform tion, I believe that the submitted information is true, accurate, and complete. Name and official title of owner or owner's Signature: authorized representative(Print) Date: f� L, d�i LL 1✓ , FP-290R(revised 5/98) Z/� L/� 7 w .ScrF(ae4 m " rrDb"'� ek RECEIPT-OF:PMRO4AL:A�F UNDERGROUND STEEL.STORAGE TANK F�vi'FR491 - NAME-AND.ADDRESS OF APPROI(ED TANK l(ARD; s;:x y . M ¢-,�- f 1e A� zr is Y - SYigi +•6•.°'R-"" F.(d hf .. .. AT ARPRJUED TANK YARD NO �:• _ _._ TankYat i LedgeF:502 CMR 3 03� I certify uJldet'penalty of.Faw Ishave personally exariuned ttie:untlerground steel storage tank delivered to thlS'appn�ved tank yard-6y firm,corporation or Y aNJassaehusetl�Fire�Psevent �RegulaUom,5U2 CM 3 00 Pro�nsl�ons k ACC Prong Un Steel S y'dls ntl valid ._ 0rtls � elfwas Issued CyLOCAI Iof F�reDe�artment `- to trans thrsta�tk tothlss 9 a aal title ,Name. M� Pp►nyedgtank yard owner or owners authetl representative # s; c tt TITLE,..._ This signedC81 t d15 s DATE SI ED P posal must`be returned to the liicahead of�the firre tl artrnent FDIU# � r.v� ,puhsaaF±t-to 502 CMR 3?00 EACH TANK MUST HAVE A RECEIPT OF DISPOSAL ' '-; �� Y�trE_:.x t*.. * y#f '' _.' � A.+y f.y. _'wk �.•.� y�:� �k _ 1}`^ C � S kS`' - ,4 s '��� ..s,.. �,� 'cry-x ,tea-t q� §�� � �` x . 4 f x �"C C tn''. �,, {,r >i.� - ki c "`t-e sry, W' c '� 'k2 k-J,R� NIyY i �- � � "a ;sn g .: _.. •�.,-x F p - �� � � � 401 N. NA ``"gaz .'.- ;-?.' r for na �rer�sed c p 'otifi non Forka-m O�4o� §p � n PRY, � Complian O> oI the=State o SOf { tre Mn>Gs6 �� � r P: Boz SW- 1 eNRoad,Stow,�MA 01775 - Hi'F `rv� �"-„'1`�ra�4. sd .h•,�' l I kp .,,� �ti+�k _t ':rie�: v _. MYh ?.re- t'� - r SALEM FI ER DEPARTMENT Ile INSPECTION AND VIOLATION REPORT DATE: STATION: , ADDRESS: litoA I NAME: T- a W� PHONE: BLDG. CLASS: ALARM CO: OFFICER: F/F: F/F: MULTIPLE BUSINESSES,RETAIL SPACES,OFFICES,ETC. OCCUPANCY PHONE# OCCUPANCY PHONE# EXTERIOR P S FAIL N/A HEATING SYSTEMS PA i FAIL N/A EXITS MSY FAIL N/A ELECTRICAL PA SS FAIL N/A FIRE ALARM SYSTEM I P S FAIL N/A FIRE EXTINGUISHERS I/PAA FAIL N/A SPRINKLERS JPASS FAIL /A , STANDPIPES IPASS FAIL / ' EMERGENCY LIGHTS I PIAS5K FAIL N/A KITCHENS PASS FAIL /A/ STORAGE PASS FAIL N/A PERMITS YES NO /A OTHER VIOLATIONS AND COMMENTS REGULAR INSP. QUAR,TERU INSP. SCHOOL INSP. Forth#16(Rev.6/2003) WHITE COPY: FIRE PREVENTION PINK COPY: OWNER r SALEM FIRE DEPARTMENT INSPECTION AND VIOLATION REPORT DATE: ® STATION: ADDRESS: ,;L 1 S- - NAME: 4 � t�-d�fiv-'\ c ro PHONE: I BLDG. CLASS: ALARM CO: OFFICER: F/F: F/F: MULTIPLE BUSINESSES,RETAIL SPACES,OFFICES,ETC. OCCUPANCY PHONE# OCCUPANCY PHONE# EXTERIOR P FAIL N/A HEATING SYSTEMS A FAIL N/A EXITS A FAIL N/A ELECTRICAL A S FAIL N/A FIRE ALARM SYSTEM A FAIL N/A FIRE EXTINGUISHERS I A S FAIL N/A SPRINKLERS T PASS FAIL / STANDPIPES IPASS FAIL N/ EMERGENCY LIGHTS PASS FAIL N/A KITCHENS PASS FAIL N/A 0 ® S STORAGE IPASS FAIL N/A PERMITS IYES NO N/A OTHER VIOLATIONS AND COMMENTS REGULAR INSP. QU22gRLYWSP. SCHOOL INSP. Form#16(Rev.6/2003) WHITE COPY: FIRE PREVENTION PINK COPY: OWNER E\TSTANT SIGNAL & ALARM CO., INC. 303 Highland Avenue Salem,Massachusetts 01970 (781)598-0323 (978)744-9070 (617)426-4205 Fax: (978)74.5-8661 Email: info@instanLalarm.com EERGLRR •FIRE•SFRINKLEri,SUPER WON-CCTTI•ACCESS CONTROL CENT&4L ST.rTIONMOMTO.RAWO SINCE 1954•AdA L aNSE R0.1147C Facsinide Transmittal Cover Sheet . Date: —1 f 2_,�V Y _ Fax No.: 1��'7��� r�D Telephone No.: To: T� . Attn.• From: Number of Pages including Cover Sheet: Comments: Please Call if Where is a Problem with Transmission This message is intended only for the use of the individual.or entity to which it is addressed and may contain information than is privileged, confidential and exempt from disclosurti under applicable laur. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication i., strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and returr. the original message to us at the above address via the LT. S, Postal Service. Thank you. -'Minding YourBusin.-55 is Our Business— ZO'd SV:trl 80OZ ZZ InE I998SVZ8Z6i:xpd Wdd7d BUiSNI Instant Signal and Alarm Co., Inc PAGE 1 OF 2 303 Highland Avenue, Salem,MA 01970 ToL: (978)744-9D70 Fax: (978)745-8661 MA License#1147C inspection Report Subscriber: Inspection Test Type: HEALTH &EDUCATION SERVICES ANNUAL FIRE INSPECTION 162 FEDERAL STREET SALEM, MA 01970 Account: 06-C2-5103 Type of Devices ANN Annundator FPP Fire Pump Power iSD Ionization Smoke $TBY Stantlby Power AP Air Pressure FPR Firs Pump Runritng JPP Jockey Pump Pourer TH Thermostat a Beam Smoke FS Fi•e Suppresaion JPR Jockey Pump Running WFP Water Flow Pressure DS Duct Smoke GV Gate Valve MB Master Box WFV Water Flaw Valve DAGT Digital Alarm Comm,Trans. H Mom MRs Mannar Pull Station F Fixed Temperature HD Heat Detector 9 Strobe FACP Fire Alarm Control Panel HS HomlStrobe SD Smoke Detector X-PASS FsFAIL V=VISUAL Device Type IDevice Location JUN 08 Comments; FACP I RIGHT OF RECEPTION DESK X SK5207 S JOUTSIDE SIDE OF BUILDING X SD IRECEPTION DESK X HD WAITING ROOM V MPS RECEPTION AREA X HS RECEPTION AREA X HS 18T FLOOR OFFICE X HS 1 ST FLOOR SIDE EXIT DOOR X MPS 1ST FLOOR SIDE EXIT DOOR X SD 1 ST FLOOR SIDE EXIT DOOR X SD OFFICE 124 HALL X HS 1OFFICE 124 HALL X HD ROOM 117 V SO BOTTOM OF STAIRS TO BASEMENT X MPS EXIT DOOR BASEMENT X H5 1EXIT DOOR BASEMENT X SD EXIT DOOR BASEMENT X HS BASEMENT ROOM#1 X SD BASEMENT STORAGE ROOMS X SD BASEMENT STORAGE ROOMS X OUTSIDE ELECTRICAL ROOM SD BASEMENT BACK STORAGE ROOM X RECORDS ROOM CONTACT PERSON' REPORT SENT TO; MEDIA 978-745-2440 COMMENTS' DATE OF INSPECTION: 6/3/2008 INSPECTED BY' JOE MCGILL REPORT PREPARED BY LISA NICKLOW ZO'd Sb:bT 800Z ZZ int T998SbZ8Z6T:xpd Wdd7d 1Nd1SNI Instant Signal and Alarm Co., Inc PAGE 2 OF 2 303 Highland Avenue, Salem,MA 01$70 Tel.: (878)744-9070 Fax: (878)746-8661 MA License 41147C Inspection Report Subscriber: Inspection Test Type: HEALTH& EDUCATION SERVICES ANNUAL FIRE INSPECTION 162 FEDERAL STREET SALEM, MA 01970 Account: Type of Devices ANN Annunciator FPP Fire Pump Power ISD Ionization Smoke STBv Standoy Power AP Air Pressure FPR Fire Pump Running JPP Jockey Pump Power TH Thermostat B Beam Smoke FS Fire Suppression JPR Jockey Pump Running VVFP Water Flow Preaaure DS Duct Smoke GV Gate Valve _ MB Master Box WFV Water Flow Valve. DACT Digital Alarm Comm.Trans. H HOm "` MP3 Manual Pull Station F FIXOd Tgmoerature HD Heat Detector S Strobe FACP Fire Alarm Control Paner HS Hom/Strobe SD Smoke Detector WASS F=FAIL V=VISUAL Device Type Device Location JUN 08 Comments: SD ELECTRICAL ROOM X SD LANDING 2ND FLOOR X HS 2ND FLOOR HALL X H5 12NO FLOOR HALL X MPS 2ND FLOOR HALL X SD 2ND FLOOR HALL X HS ROOM 212 HALL X SD ROOM 219 HALL X SD ILANDING 3RD FLOOR X SD 13RD FLOOR FRONT OF 218 X SD 13RD FLOOR FRONT OF 314 . X HS 3RD FLOOR FRONT OF 314 X HS 3RD FLOOR EXIT DOOR X MPS 3RD FLOOR EXIT DOOR X SD 3RD FLOOR EXIT DOOR X MPS 4TH FLOOR X HIS 4TH FLOOR X SO 4TH FLOOR X SD 14TH FLOOR X CONTACT PERSON; REPORT SENT TO: COMMENTS: DATE OF INSPECTION: 6/3/2008 INSPECTED BY: JOE MCGILL REPORT PREPARED BY LISA NICKLOW M'd Sb:VT SWZ ZZ Inr T998SVZ8Z6T:xPJ Wdd7d 1Wd1SWI n SALEM FIRE DEPARTMENT INSPECTION AND VIOLATION REPORT DATE: - TATION: ADDRESS: S NAME: PHONE: JBLDG. CLASS: ALARM CO: OFFICER: .- F/F: 0 F/F: MULTIPLE BUSINESSES,RETAIL SPACES,OFFICES,ETC. OCCUPANCY PHONE# OCCUPANCY PHONE # EXTERIOR LPASS1 FAIL N/A HEATING SYSTEMS YPASV FAIL N/A EXITS VDAS§2 FAIL N/A ELECTRICAL PAS FAIL N/A FIRE ALARM SYSTEM PASS f AIL N/A FIRE EXTINGUISHERS PASS FAIL N/A SPRINKLERS PASS FAIL A STANDPIPES IPASS FAIL / S EMERGENCY LIGHTS PASS JFAIL N/A KITCHENS PASS FAIL N/A STORAGE ASS FAIL N/A PERMITS YES NO N/A OTHER VIOLATIONS AND COMMENTS i REGULAR INSP. QUARTERLY INSP. SCHOOL INSP. Form#16(Rev.6/2003) WHITE COPY: FIRE PREVENTION PINK COPY: OWNER Instant Signal and Alarm Co., Inc PAGE 1 OF 2 303 Highland Avenue, Salem, MA 01970 Tel.: (978)744-9070 Fax: (978)745-8661 MA License#1147C Inspection Report Subscriber: Inspection Test Type: HEALTH & EDUCATION SERVICES ANNUAL FIRE INSPECTION 162 FEDERAL STREET SALEM, MA 01970 Account: 06-02-5103 Type of Devices ANN Annunciator FPP Fire Pump Power ISD Ionization Smoke STBY Standby Power AP Air Pressure FPR Fire Pump Running JPP Jockey Pump Power TH Thermostat B Beam Smoke FS Fire Suppression JPR Jockey Pump Running WFP Water Flow Pressure DS Duct Smoke GV Gate Valve MB Master Box WFV Water Flow Valve DACT Digital Alarm Comm.Trans. H Horn MPS Manual Pull Station F Fixed Temperature HD Heat Detector S Strobe FACP Fire Alarm Control Panel HS Horn/Strobe SD Smoke Detector X=PASS F=FAIL V=VISUAL Device Type Device Location JUN 08 Comments: FACP RIGHT OF RECEPTION DESK X SK5207 S OUTSIDE SIDE OF BUILDING X SD RECEPTION DESK X HD WAITING ROOM V MPS RECEPTION AREA X HS RECEPTION AREA X HS 1ST FLOOR OFFICE X HS 1ST FLOOR SIDE EXIT DOOR X MPS 1ST FLOOR SIDE EXIT DOOR X SD 1ST FLOOR SIDE EXIT DOOR X SD OFFICE 124 HALL X HS OFFICE 124 HALL X HD ROOM 117 V SD BOTTOM OF STAIRS TO BASEMENT X MPS EXIT DOOR BASEMENT X HS EXIT DOOR BASEMENT X SD EXIT DOOR BASEMENT X HS BASEMENT ROOM#1 X SD BASEMENT STORAGE ROOMS X SD BASEMENT STORAGE ROOMS X OUTSIDE ELECTRICAL ROOM SD IBASEMENT BACK STORAGE ROOM X RECORDS ROOM CONTACT PERSON: REPORT SENT TO: MEDIA 978-745-2440 COMMENTS: DATE OF INSPECTION: 6/3/2008 ¢ INSPECTED BY: S�l�mD 7��z/Ott JOE MCGILL REPORT PREPARED BY LISA NICKLOW Instant Signal and Alarm Co., Inc PAGE 2 OF 2 303 Highland Avenue, Salem, MA 01970 Tel.: (978)744-9070 Fax: (978)745-8661 MA License#1147C Inspection Report Subscriber: Inspection Test Type: HEALTH & EDUCATION SERVICES ANNUAL FIRE INSPECTION 162 FEDERAL STREET SALEM, MA 01970 Account: Type of Devices ANN Annunciator FPP Fire Pump Power ISD Ionization Smoke STBY Standby Power AP Air Pressure FPR Fire Pump Running JPP Jockey Pump Power TH Thermostat B Beam Smoke FS Fire Suppression JPR Jockey Pump Running WFP Water Flow Pressure IDS Duct Smoke GV Gate Valve MB Master Box WFV Water Flow Valve DACT Digital Alarm Comm.Trans. H Horn MPS Manual Pull Station F Fixed Temperature HD Heat Detector S Strobe FACP Fire Alarm Control Panel HS Horn/Strobe SD Smoke Detector X=PASS F=FAIL V=VISUAL Device Type Device Location JUN 08 Comments: SD ELECTRICAL ROOM X SD LANDING 2ND FLOOR X HS 2ND FLOOR HALL X HS 2ND FLOOR HALL X MPS 2ND FLOOR HALL X SD 2ND FLOOR HALL X HS ROOM 219 HALL X SD ROOM 219 HALL X SD LANDING 3RD FLOOR X SD 3RD FLOOR FRONT OF 218 X SD 3RD FLOOR FRONT OF 314 X HS 3RD FLOOR FRONT OF 314 X HS 3RD FLOOR EXIT DOOR X MPS 3RD FLOOR EXIT DOOR X SD 3RD FLOOR EXIT DOOR X MPS 4TH FLOOR X HS 4TH FLOOR X SD 4TH FLOOR X SD 4TH FLOOR X CONTACT PERSON: REPORT SENT TO: COMMENTS: DATE OF INSPECTION: 6/3/2008 INSPECTED BY: JOE MCGILL REPORT PREPARED BY LISA NICKLOW