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HomeMy WebLinkAboutChauncy St. #54 - 2008-20100 a SOVEREIGN CONSULTING INC. May 21, 2610 � UPS#1Z96964F0395593036 Mr. Scott Leite, Health Agent Board of Health Town Hall 6 Park Row Mansfield, MA 02048 Re: Confirmatory Notice of Activity and Use Limitations Former Shell -Branded Service Station 54 Chauncy Sheet Mansfield, Massachusetts RTN 4-18634 & 4-11144 Dear Mr. Leite: In accordance with the Massachusetts Contingency Plan (MCP) 310 CMR 40.1403 (7)(a), notification is hereby made that Confirmatory Activity and Use Limitations (AUL) were recorded on the deed of the above -referenced property on May 12, 2010. Copies of the Confirmatory AUL's are attached. In addition, legal notices were published in The Sun Chronicle on May 19, 2010. The Confirmatory AUL's restrict future uses of the property. Copies of the reports for this site can be obtained at the Massachusetts Department of Environmental Protection Southeast Regional Office located at 20 Riverside Drive, Lakeside, MA 02347. If you have any questions please call the undersigned at (508) 339-3200. Sincerely, SOVEREIGN CONSULTING INC. Neil R. Schofield Senior Project Manager cc: David B. Weeks, Motiva Enterprises LLC MassDEP SERO Sovereign File - EQ881 905B S. Main Street, Unit 202 • Mansfield, MA 02048 • Tel: 508-339-3200 • Fax: 508-339-3248 August 20, 2008 Mansfield Board of Health, Environmental Affairs 6 Park Row F�, H 2 2 2008 Mansfield, Massachusetts 02048 Mr. John D'Agostino Town Manager 6 Park Row Mansfield, Massachusetts 02048 Re: Availability & Summary of Phase IV Remedy Implementation Plan Report Former Shell -branded Gasoline Station 54 Chauncy Street Mansfield, Massachusetts MassDEP RTN 4-18634 To Whom It May Concern: In accordance with the Massachusetts Contingency Plan (MCP) 310 CMR 40,1403 (3)(e), this correspondence serves as notification that a Phase IV Remedy Implementation Plan Report was submitted to the Massachusetts Department of Environmental Protection (MassDEP) for the above -referenced location (the disposal site). The selected remedial action alternatives for the disposal site is monitored natural attenuation (MNA). Based on available data, no sensitive receptors are currently at risk due to the groundwater impact. Active remedial monitoring will continue until, at minimum, groundwater analytical data meet the applicable MCP Method 1 Groundwater Standards. A copy of the Phase IV Remedy Implementation Plan Report, as well as all other applicable documents pertaining to the subject site, is available for review at the MassDEP Southeast Regional Office located at 20 Riverside Drive, Lakeside, MA 02347. If you have any questions regarding this submittal, please feel free to contact the undersigned or Mr. David B. Weeks of Motiva at 845-462-5225. Sincerely, SOVEREIGN CONSULTING, INC. Nil R. Sch � �=C Neil R. Schoheld Project Manager cc: Mr. David Weeks, Motiva Enterprises LLC MassDEP SERO Phase IV Remedy Implementation Plan Report Package Linda S. Falk, C.G., P.G., LSP Senior Project Manager 905B S. Main Street, Unit 202 • Mansfield, MA 02048 • Tel: 508-339-3200 • Fax: 508-339-3248 December 23, 2008 UPS# 1Z 969 64F 03 9486 4889 Mr. Scott Leite, Health Agent Board of Health Town Hall 6 Park Row Mansfield, MA 02048 Re,` Notice of Activity ani 54 Chauncy Street Mansfield, Massachusetts RTN 4-18634 W:I I A 1) 20N In accordance with the Massachusetts Contingency Plan (MCP) 310 CMR 40.1403 (7)(a), notification is hereby made that an Activity and Use Limitation (AUL) was recorded on the deed of the above -referenced property on November 18, 2008. A complete copy of the AUL is attached. In addition, a legal notice will be published in The Sun Chronicle on December 24, 2008. The AUL restricts future uses of the property. Copies of the reports for this site can be obtained at the Massachusetts Department of Environmental Protection Southeast Regional Office located at 20 Riverside Drive, Lakeside, MA 02347. If you have any questions please call the undersigned at (508) 339-3200. Sincerely, SOVEREIGN CONSULTING, INC. t (t" 1) Neil R. Schofield Project Manager cc: MassDEP SERO David B. Weeks, Motiva Enterprises LLC 905B S. Main Street, Unit 202 • Mansfield, MA 02048 • Tel: 508-339-3200 • Fax: 508-339-3248 Pnviroumental services executed safely alld. consistently. NOTICE OF ACTIVITY AND USE LIMITATIONS Former Shell -Branded Service Station 54 Chauncy Street Mansfield, Massachusetts SAP #137787 MassDEP RTN 4-18634 July 15, 2008 Prepared for; Motiva Enterprises LLC PMB 301,1830 South Road, Unit 24 Wappingers Falls, New York 12590 Prepared by: Sovereign Consulting Inc. 905B South Main Street Suite #202 Mansfield, MA 02048 Sovereign File #EQ881 Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station 54 Chauncy Street Mansfield MA ' ' 4 A Bi r l r n�XTmVXIm r\JAIV1 W/O .................................................................................... EXHIBITA.................................................................................... EXHIBITB..................................................................................... EXHIBITC..................................................................................... SITEHISTORY.............................................................................. REASON FOR ACTIVITY AND USE LIMITATION .......................... ACTIVITIES AND USES CONSISTENT WITH THE AUL OPINION. ACTIVITIES AND USES INCONSISTENT WITH THE AUL OPINIO OBLIGATIONS AND CONDITIONS ............................................... SUMMARY AND CONCLUSIONS OF AUL OPINION .................... REFERENCE DOCUMENTS.......................................................... LSP CERTIFICATION OF AUL OPINION .................................... EXHIBITD.................................................................................... ATTACHMENTS Attachment A - Copy of Public Involvement Notification Letters I ............... 9 ............. 14 14 ...... ........ I.......................... 15 ......................................... 15 ......................................... 15 ......................................... 16 ......................................... 16 ....... 17 i Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station 54 Chauncy Street Mansfield MA FORM 1075 NOTICE OF ACTIVITY AND USE LIMITATION M.G.L. c. 21E, § 6 and 310 CMR 40.0000 Disposal Site Name: Former Shell -Branded Service Station, 54 Chauncy Street, Mansfield, Massachusetts DEP Release Tracking No.(s): 4-18634 (includes RTN 4-11144) This Notice of Activity and Use Limitation ("Notice") is made as of this /S� day of 20A by Motiva Enterprises LLC, with an address of PMB 301, 1830 South Road, Unit 2&p s Falls, New York 12590, together with Mr. Walid Samrout of the Walid Samrout Corporation Inc., with an address of 54 Chauncy Street, Mansfield, MA 02048 ("Owner"). WITNESSETH: WHEREAS, Mr. Walid Samrout of the Walid Samrout Corporation Inc., with an address of 54 Chauncy Sheet, Mansfield, MA 02048, is the owner in fee simple of that certain parcel of land located in Mansfield, Bristol County, Massachusetts with the buildings and improvements thereon, pursuant to a deed recorded with the Bristol County Registry of Deeds in Book 13882, Page 157. WHEREAS, said parcel of land, which is more particularly bounded and described in Exhibit A, attached hereto and made a part hereof ("Property") is subject to this Notice of Activity and Use Limitation. The Property is shown on a plan entitled "Site Plan: Prepared for Motiva Enterprises LLC 54 Chauncy Sheet Mansfield, Massachusetts" Surveyed by Don Rosa Professional Land Surveyor, April 5, 2004 recorded with Bristol County Registry of Deeds, Book 424, Page 60. WHEREAS, the Property comprises all of a disposal site as the result of a release of oil and/or hazardous material. Exhibit B is a sketch plan showing the relationship of the Property subject to this Notice of Activity and Use Limitation to the boundaries of said disposal site existing within the limits of the Property and to the extent such boundaries have been established. Exhibit B is attached hereto and made a part hereof; and WHEREAS, one or more response actions have been selected for the Disposal Site in accordance with M.G.L. c. 21E ("Chapter 210) and the Massachusetts Contingency Plan, 310 CMR 40.0000 ("MCP"). Said response actions are based upon (a) the restriction of human access to and contact with oil and/or hazardous material in soil and/or (b) the restriction of certain activities occurring in, on, through, over or under the Property. The bash for such restrictions is set forth in an Activity and Use Limitation Opinion ("AUL Opinion"), dated /S� (which is attached hereto as Exhibit C and made a part hereof); NOW, THEREFORE, notice is hereby given that the activity and use limitations set forth in said AUL Opinion are as follows: 1. Activities and Uses Consistent with the ALL Opinion, The AUL Opinion provides that a condition of No Significant Risk to health, safety, public welfare or the environment exists Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station 54 Chauncy Sheet Mansfield MA for any foreseeable period of time (pursuant to 310 CMR 40.0000) so long as any of the following activities and uses occur on the Property: (i) Commercial, retail, and industrial activities; (ii) Activities consistent with the above uses, including but not limited to landscaping and routine maintenance of landscaped areas, vehicular and pedestrian traffic, vehicular parking, and other non -intrusive activities which do not cause and/or result in direct contact with, disturbance of, and/or relocation of, soil currently located at depths of 4-17 feet below grade surface; (iii) Excavation associated with emergency or short term (six months or less) underground utility and/or construction work which is likely to disturb soil currently located at depths of 4-17 feet below grade surface provided that it is conducted in accordance with a Soil Management Plan and a Health and Safety Plan prepared and implemented in accordance with Obligations (i) and (it) of this Notice prior to the commencement of such activity; (iv) Activities and uses which are not identified by this Notice as being inconsistent with maintaining a condition of No Significant Risk; (v) Such other activities or uses which, in the Opinion of an LSP, shall present no greater risk of harm to health, safety, public welfare or the environment than the activities and uses set forth in this Paragraph; and (vi) Such other activities and uses not identified in Paragraph 2 as being Activities and Uses Inconsistent with the AUL. 2. Activities and Uses Inconsistent with the AUL Opinion. Activities and uses which are inconsistent with the objectives of this Notice of Activity and Use Limitation, and which, if implemented at the Property, may result in a significant risk of harm to health, safety, public welfare or the environment or in a substantial hazard, are as follows: (i) Use of the property as a residence, school, nursery, daycare, recreational area, and/or other such use at which a child's presence is likely on a frequent basis; (it) Any short-term (six months or less) activity including, but not limited to, excavation which is likely to disturb soil currently located beneath pavement or the building slab without the prior development and implementation of a Soil Management Plan and a Health and Safety Plan in accordance with Obligations (i) and (ii) of this Notice; (iii) Any long-term (greater than six months) activity which is likely to disturb soil currently located at depths of 4-17 feet below grade surface unless such activity is first evaluated by an LSP who renders an Opinion which states that such activity is consistent with maintaining a condition of No Significant Risk; and (iv) Relocation of soil currently located at depths of 4-17 feet below grade surface, unless such activity is first appropriately evaluated by an LSP who renders an Opinion which states that such relocation is consistent with maintaining a condition of No Significant Risk. 2 Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station 54 Chauncy Street Mansfield MA 3. Obligations and Conditions Set Forth in the AUL Opinion. If applicable, obligations and/or conditions to be undertaken and/or maintained at the Property to maintain a condition of No Significant Risk as set forth in the ALL Opinion shall include the following: (i) A Soil Management Plan must be prepared by an LSP and implemented prior to the commencement of any activity that is likely to disturb soil currently located at depths of 4-17 feet below grade surface. The Soil Management Plan must be prepared in accordance with the guidelines discussed in the Activity and Use Limitation Opinion attached hereto as Exhibit C; (ii) A Health and Safety Plan must be prepared and implemented prior to the commencement of any activity that is likely to disturb soil currently located at depths of 4-17 feet below grade surface. The Health and Safety Plan must be prepared in accordance with the guidelines discussed in the Activity and Use Limitation Opinion attached hereto as Exhibit C; and (iii) The soil currently located at depths of 4-17 feet below grade surface may not be relocated, unless such activity is first appropriately evaluated by an LSP who renders an Opinion which states that such relocation is consistent with maintaining a condition of No Significant Risk. 4. Proposed Changes in Activities and Uses. Any proposed changes in activities and uses at the Property which may result in higher levels of exposure to oil and/or hazardous material than currently exist shall be evaluated by an LSP who shall render an Opinion, in accordance with 310 CMR 40.1080 et seq., as to whether the proposed changes will present a significant risk of harm to health, safety, public welfare or the environment. Any and all requirements set forth in the Opinion to meet the objective of this Notice shall be satisfied before any such activity or use is commenced. 5. Violation of a Response Action Outcome. The activities, uses and/or exposures upon which this Notice is based shall not change at any time to cause a significant risk of harm to health, safety, public welfare, or the environment or to create substantial hazards due to exposure to oil and/or hazardous material without the prior evaluation by an LSP in accordance with 310 CMR 40.1080 et seq., and without additional response actions, if necessary, to achieve or maintain a condition of No Significant Risk or to eliminate substantial hazards. If the activities, uses, and/or exposures upon which this Notice is based change without the prior evaluation and additional response actions determined to be necessary by an LSP in accordance with 310 CMR 40.1080 et seq., the owner or operator of the Property subject to this Notice at the time that the activities, uses and/or exposures change, shall comply with the requirements set forth in 310 CMR 40,0020. 6. Incorporation Into Deeds, Mortgages Leases and Instruments of Transfer This Notice shall be incorporated either in full or by reference into all future deeds, easements, mortgages, leases, licenses, occupancy agreements or any other instrument of transfer, whereby an interest in and/or a right to use the Property or a portion thereof is conveyed. Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station 54 Chauncy Street Mansfield MA Owner hereby authorizes and consents to the filing and recordation and/or registration of this Notice, said Notice to become effective when executed under seal by the undersigned LSP, and recorded and/or registered with the appropriate Registry of Deeds. WITNESS the execution hereof under seal this k day of , rY 204 ner ws. Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station, 54 Chauncy Street Mansfield MA COMMONWEALTH OF MASSACHUSETTS Bristol County,ss �f�„ „'— 206g- D- On this / day of 20d�before me, the undersigned notary public, personally appeared ti��SyMxRayr proved to me through satisfactory evidence of identification, which were Qr rofi(� l�nU+� to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he signed it voluntarily for its stated purpose. ( as Walid Samrout for the Walid Samrout Corporation, Inc.) b-3.5. ,l Notary Public PAULEDWIN Notary public EDY lAa 1u�,,�►t�Gt jl� r�p Comh ou My commission Expire" yam/ Matoh 61203 Seal of Notary The undersigned LSP hereby certifies that he executed the aforesaid Activity and Use Limitation Opinion attached hereto as Exhibit C and made a part hereof and that in his Opinion this Notice of Activity and Use Limitation is consistent with the terms set forth in said Activity and Use Limitation Opinion. Date: !s e Linda S. Falk, LSP L51' Seal Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station, 54 Chauncy Street Mansfield MA COMMONWEALTH OF MASSACHUSETTS Bristol County, ss 20 0 iti- On this 11 day of —1l 20006 before me, the undersigned notary public, personally appeared uY�Z'z� SYlr1+&Vr— proved to me through satisfactory evidence of identification, which were 11% 4440'✓ to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he signed it voluntarily for its stated purpose. (as Walid Samrout for the Walid Samrout Corporation, Inc.) Notary Public Upon recording, return to: Mr. Walid Samrout Walid Samrout Corporation, Inc. 54 Chauncy Street Mansfield, MA 02048 David Weeks Motiva Enterprises LLC PMB 301 1830 South Road Unit 24 Wappingers Falls, NY 12590 PAULEoWIN i(ENNEDY Notary Public �CoMy Commission s Massachusetts My March 8,, 2013ires Seal of Notary Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station, 54 Chauncy Street Mansfield MA EXHIBIT A Legal Description Parcel of Land Containing Area Subject to the AUL Mansfield Assessor's Parcel ID - Map 22 Lot 09 All that certain tract or parcel of land situated in the City of Mansfield, Bristol County, State of Massachusetts, with a physical address of 54 Chauncy Sheet, and more particularly described as follows: BEGINNING at a drill hole set at the southerly side of Chauncy Street at the northeasterly end of the curved right of way line connecting the easterly side of North Main Street with the said southerly side of Chauncy Street and extending thence: 1) bounding northerly on said southerly side of Chauncy Street North 62 degrees 54 minutes 25 seconds East 119 feet to a point; thence 2) bounding easterly on land now or formally of Attillo Pedini South 5 degrees 39 minutes 25 seconds East 123.46 feet to a point; thence 3) bounding southerly on land now or formally of Luigi Giovi no and Caarmela Giovino South 84 degrees 20 minutes 35 seconds West 157.09 feet to a point; thence 4) bounding westerly on said easterly side of North Main Street North 4 degrees 26 minutes 55 seconds West 19.16 feet to a point; thence 5) bounding westerly on said North Main Street North 84 degrees 33 minutes 05 seconds East 3.21 feet to the southerly end of said curved right of way line connecting aid easterly side of North Main Street with the southerly side of Chauncy Sheet; thence 6) bounding on said connecting highway right of way line and running northwardly to northeastwardly along the curve thereof which has a radius of 67.35 feet the arc distance of 78.79 feet to the point and point of BEGINNING. DEED REFERENCE: Deed dated July 15, 2004 recorded in Book 13882, Page157, Bristol County Registry of Deeds, Taunton, Massachusetts. [Parcel of land subject to this Notice of Activity and Use Limitation is shown on a plan recorded in the Bristol County Registry of Deeds in Book yZJ Page 40..1 Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station 54 Chauncy Street Mansfield MA EXHIBIT B Sketch Plan ! S � - ! u _ w\g§3`m E i Il3aIS /W \1�JO N Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station 54 Chauncy Street Mansfield MA EXHIBIT C Activity and Use Limitation Opinion Subject Site: Former Shell -Braided Service Station #137787 54 Chauncy Street Mansfield, MA Site History The subject property is located at 54 Chauncy Street in Mansfield, Massachusetts at the southeastern corner of the intersection of Chauncy Street and North Main Street. The "disposal site" is defined as the facility and other properties where oil and/or hazardous material (OHM) have come to be located as a result of the release from the facility. The limits of the disposal site for RTN 4-18634 fall within the disposal site limits of RTN 4-11144, assigned on March 25, 1995 for historical releases of oil and hazardous materials. On May 14, 2004, an Activity and Use Limitation (AUL) was recorded for RTN 4- 11144 limiting the facility use to commercial and industrial uses which do not result in contact with petroleum impacted soil at depths of 4 to 16 feet below grade surface (bgs). A Class A-3 Response Action Outcome Statement with Method 3 risk assessment was submitted to Massachusetts Department of Enviromuental Protection (MassDEP) for RTN 4-11144 on June 25, 2004. The disposal site is a former Shell -branded service station currently utilized as an Exxon -branded retail service station. The facility consists of a single -story station building with a small convenience store, restrooms, office area, and three automobile service bays located on a 12,295 square foot lot. The facility is situated in a commercial and residential area of Mansfield. Surrounding properties include the following: North: Chauncy Street, beyond which is a Bank of America, South: A multi -family residential property at 333 North Main Street, beyond which are additional multifamily residential properties, East: Mansfield Auto Pros, an auto repair and carwash facility, West: North Main Street, beyond which is a strip mall and Thomas Sheet. Closed RTN 4-11144 According to the town of Mansfield municipal records and historical reports, a release of 1,176 gallons of gasoline occurred from a 4,000 gallon UST at the facility on September 22, 1980. The tank was repaired and coated with fiberglass following the release. Fifteen test borings were advanced at the facility in September 1980 by ARCO (the owner/operator of the service station at the time of the release) to evaluate soil quality. Soil impacts were noted in one borehole (on the southern portion of the facility). No further evaluation was conducted until 1986. In July 1986 Groundwater Technologies, Inc. (GTI) advanced three soil borings (SB-1 tluough SB-3) and two groundwater -monitoring wells (GT-1 and GT-2) at the site as part of a Type B Location Assessment. Soil and groundwater samples were collected and analyzed. Benzene, toluene, ethylbenzene, and xylenes (BTEX) compounds and volatile organic compounds (VOCs) were noted in soil and water samples collected at the site. A description of site history, local land use, and likely receptors was included in the GTI report. Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station, 54 Chauncv Street Mansfield MA On December 5, 1989, a release of gasoline resulting from a dispenser overflow was reported to the MassDEP. Less than 10 cubic yards of impacted soil were removed following the release. In February 1990, GTI advanced one additional soil boring (SB-4) and four groundwater monitoring wells (GT-3 through GT-6). In November 1994, GTI collected additional groundwater samples at the site. Laboratory data from the sampling event documented concentrations of benzene greater than the MassDEP reportable concentrations (RCGW-1) in monitoring wells GT-5 and GT-6. This condition triggered a 120 day reporting requirement and the release was reported to the MassDEP on February 21, 1995. MassDEP issued A Notice of Responsibility to Shell on March 22,1995 and RTN 4-11144 was assigned. Lincoln Environmental Inc. (Lincoln) submitted a Phase I - Initial Site Investigation to the MassDEP on January 25, 1996, documenting site activities and the advancement of soil borings and installation of the groundwater monitoring wells. A Numerical Ranking System (NRS) Score sheet was submitted with the Phase I. The NRS score sheet was 287 and the subject facility was classified as a Tier II Disposal Site, The Phase I indicated that four gasoline USTs and one waste oil UST were removed from the site in 1986, however no details of the removal were available. Lincoln completed an Underground Storage Tank (UST) Closure Assessment on May 30,1997 summarizing the removal of a 550-gallon waste oil UST. This tank was a fiberglass walled tank installed in 1986. A 275-gallon aboveground storage tank installed on the east side of the station building replaced the waste oil UST. During the removal, Lincoln Environmental screened soil with a PID and collected endpoint samples from the UST grave. PID readings were all below instrument detection limits. Soil samples were analyzed for total petroleum hydrocarbons (TPH), VOCs, polycyclic aromatic hydrocarbons (PAHs), polychlorinated biplienyls (PCBs), and RCRA 8 metals. No TPH, VOC, PAH, or PCB compounds were detected in any of the soil samples. Low concentrations of arsenic, barium, chromium, and lead were detected at concentrations below RCS-1 standards. The lead concentration in this area was 6.3 mg/kg. On June 8, 2000, EnviroTrac completed a Hydraulic Lift Closure Report which summarized the removal of one hydraulic lift from the service bay closest to the cashier area. EnviroTrac completed a Tier II Extension on May 3, 2001. MassDEP issued a Notice of Noncompliance (NON) on July 15, 2001. In accordance with the requirements of the NON, a level 1 Soil Gas Screening was completed at the disposal site on July 16, 2001. A total of eight temporary soil gas probes were installed at the site in the vicinity of the facility building and the residence located at 333 North Main Street. A Level 1 soil gas screening was conducted and PID readings were all below instrument detection limits. A letter report summarizing the results of the soil gas sampling was submitted to the MassDEP on July 30, 2002. On September 18, 2001, EnviroTrac submitted a Release Action Measure (RAM) Plan for the removal of a second hydraulic lift located in the center service bay. A total of 10.92 tons of impacted soil were removed during the removal and transported to Aggregate Industries in Stoughton, Massachusetts for asphalt -batch recycling. On January 11, 2002, EnviroTrac submitted a RAM completion Report. Samples collected from excavated soil associated with the RAM were analyzed for'TPH, VOCs, PCBs, RCRA-8 metals, flashpoint, pH, and sulfide/cyanide reactivity. There were no PCBs detected. The maximum detected lead concentration was 165 milligrams per kilogram. EnviroTrac submitted a Phase II Comprehensive Site Assessment (Phase II CSA) report and a Phase III Remedial Action Plan (Phase III RAP) report on September 30, 2001. The Phase II defined the limits of Contaminants of Concern (COCs) at the subject facility. Groundwater impacted with concentrations of COCs above applicable standards was located along the southern facility boundary to the south and southwest of the station building. Groundwater impacts likely extended beneath the northern portion of the residence at 333 North Main Street, ranging in depths from approximately eight feet below grade surface (bgs) to a maximum depth of 25 feet bgs. COCs related to RTN 4-11144 included volatile petroleum hydrocarbons (VPH) compounds, extractable petroleum hydrocarbons (EPH) compounds, naphthalene, methyl tert-butyl ether (MTBE), dissolved lead, BTEX, and PAH compounds. Impacted soil was present in the southern portion of the site, to the south of the dispenser islands, and the station building at a depth of approximately 9 to 15 feet bgs. The Phase III RAP identified monitored natural 10 Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station 54 Chauncy Street Mansfield MA attenuation and injection of oxygen -releasing material (ORM) as the selected remedial action alternatives (RAA) for the disposal site. EnviroTrac submitted a Phase IV Remedial Implementation Plan on January 30, 2002. The Phase IV report detailed the selected RAA for the subject facility (injection of oxygen releasing material and quarterly sampling and monitoring of groundwater). On February 20, 2002 powdered magnesium peroxide was injected into borings advanced at the disposal site. On March 29, 2002, EnviroTrac submitted a Phase IV Final Inspection Report and a Phase V Remedy Operation Status Report (ROS) to the MassDEP. Inspection and monitoring reports were completed for the site on September 19, 2002, March 18, 2003, September 19, 2003, and March 19, 2004. The groundwater sampling frequency was reduced to semi- annual in September 2003 due to decreases in COCs in monitoring wells across the site. On May 14, 2004 an AUL was recorded for the facility. The AUL restricts the use of the facility as a residence, school daycare, nursery, recreational area, or any activity that would disturb impacted soil at depths of 4 to 16 feet bgs, thus eliminating long-term dermal exposures to impacted soil. On June 25, 2004 a Class A-3 RAO with Method 3 risk assessment was submitted to MassDEP for RTN 4-11144. RTN 4-18634 In July 2004, as part of a property transaction between Motiva and Walid Sarnrout, the remaining hydraulic lift in the eastern service bay of the station building and a floor drain (formally filled with concrete) adjacent to the hydraulic lift were removed. Work completed during the removal was conducted in accordance with the health and safety plan prepared for RTN 4-11144, completed by appropriately trained personnel and overseen by a licensed site professional (LSP) in accordance with AUL requirements associated with RTN 4-11144. On July 6, 2004, EnviroTrac observed the removal of the remaining hydraulic lift performed by Petroleum Engineering (PE) of Bellingham, Massachusetts. During the excavation, soil was screened by EnviroTrac personnel with a photoionization detector (PID) equipped with a 10.6 election volt (eV) lamp in accordance with MassDEP jar headspace analytical screening procedures. All total organic volatiles (TOV) concentrations were below instrument detection limits (BDL) Soil samples were collected from the completed excavation and submitted to New England Testing Laboratory (NET) of North Providence, Rhode Island for analysis of EPH, RCRA 8 metals, PCBs and VOCs. Fill material including gravel, brick, coal, cinderblock, glass, concrete, and asphalt were observed in the hydraulic lift excavation. During the hydraulic lift removal activities EnviroTrac assessed the location of former drainage lines from the service bay area. One former drainage line was discovered leading towards the rear of the station building. The drain line entered an approximately two foot square subsurface structure sealed beneath the concrete floor (floor drain trap) located behind the service bay in a separate room. EnviroTrac collected a sample from beneath the base of the structure and submitted the sample in accordance with chain of custody procedures to NET for analysis of VPH, EPH, RCRA 8 metals, PCB and VOC analyses, Approximately half of a 55-gallon drum was filled with impacted soil based on visual and olfactory observations. The drum was properly labeled and stored on the site pending characterization. Coal and slag were observed in the soil surrounding the drain lines indicating urban fill material underlying the building. An additional exploratory excavation was completed on July 7, 2004 to determine the direction of former discharge of lines leading from the trap. Based on excavation and snaking the lines, the line discharged northeast of the building. Concentrations of lead were detected exceeding reportable concentrations RCS-1 in the soil samples collected from three of the sidewalls of the hydraulic lift excavation, however within the range of lead concentrations documented by MassDEP as background concentrations in urban fill materials. No concentrations of EPH, VOCs or PCBs were detected in soil samples from the hydraulic lift area. With the exception of lead, concentrations of the remaining RCRA 8 metals were below MassDEP published background concentrations for "natural soil." A sample of slag was sent to NET for analysis of lead. The sample was crushed at the lab and analyzed. The results indicated that elevated lead concentrations were not present in that sample of slag. 11 Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station 54 Chauncy Street Mansfield MA Concentrations of EPH were detected above RCS-1 standards in one sample collected from the floor drain trap at 2' bgs. No concentrations of VOCs, PCBs or PAHs were detected in the sample from the floor drain trap, while concentrations of RCRA 8 metals detected in the floor drain trap did not exceed background concentration of "Natural Soil." On July 15, 2004, EnviroTrac continued work to remove the floor drain trap. PE removed the structure and excavated by hand to a depth of approximately 4.5 feet bgs. Excavated soil was screened by EnviroTrac personnel hi accordance with MassDEP jar headspace analytical screening procedure. All TOV concentrations were BDL. Soil samples were collected from the completed sidewalls and bottom of the excavation and submitted in accordance with chain of custody procedures to NET for analysis of VPH, EPH, RCRA 8 Metals, VOCs and PCBs. No samples were collected from the western wall of the excavation because the excavation extended to the concrete footing supporting a building wall. Additional drain piping was discovered in the base of the floor drain trap, leading toward the east. Approximately 2.5 cubic yards of impacted soil was stockpiled on and covered with polyethylene sheeting on -site pending disposal characterization. No concentrations of VOCs were detected in the floor drain tap sidewall samples above RCS-1 standards. Concentrations of VPH, EPH, and PCBs were detected below RCS-1 standards. Concentrations of PAHs were detected above RCS-1 standards in the base of the excavation. Concentrations of lead were also detected above RCS-1 standards and exceeded upper concentrations limits (UCLs). Lead and EPH concentrations that exceeded RCS-1 standards triggered a 120 day reporting requirement (notification discussion summarized below) because the concentration were not previously identified during assessment of RTN 4-11144. Detected concentrations of the remaining RCRA-8 metals were consistent with MassDEP documented background concentrations of "Natural Soil." On August 16 and 17, 2004 excavation continued in the former floor drain trap area. EQ Northeast of Wrentham, Massachusetts excavated impacted soil with a vacuum excavator to remove lead impacted soil at the bottom of the floor drain tap. An EnviroTrac scientist screened soil during excavation following MassDEP jar headspace analytical screening procedures. The excavation was advanced to approximately 7.5 feet bgs. Soil samples were collected from the completed excavation and shipped to NET in accordance with chain of custody documentation for analysis of VPH, EPH, VOCs, RCRA-8 metals, and PCBs. Concentrations of EPH and metals were detected below applicable Method 1 S-1 standards. Asphalt and concrete were observed throughout the excavation depth. During the August 16 and August 17, 2004 excavation, the drain lines were exposed to determine the discharge location of the floor drain trap. A series of small excavations tracing the lines revealed an undiscovered oil water separator located approximately 14 feet north of the southeast corner of the facility building. The oil water separator manhole was buried approximately one foot bgs. The manhole cover was removed and the oil water separator appeared to be filled with crushed stone. The stone was excavated to approximately five feet bgs. Water was encountered in the oil water separator at approximately five feet bgs and the excavation was terminated. Approximately five cubic yards of additional impacted soil was stockpiled and subsequently disposed of. Soil samples were collected from the four sides and bottom of the excavation and submitted using chain of custody procedures to NET for VPH, EPH, RCRA 8 metals, PCBs, and VOCs. Soil endpoint samples from the oil water separator excavation contained concentrations of lead, PAHs, EPH, and VPH above applicable Method 1 S-1 concentrations. Ash, coal, and slag materials consistent with urban fill were observed in soil surrounding the oil/water separator. The PAH concentrations are most likely related to these materials. However, lead concentrations exceeded MassDEP published background lead concentrations for urban coal ash fill. 12 Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station, 54 Chauncy Street Mansfield MA The concentrations of lead and PAHs detected during excavation of the floor drain trap and oil water separator above RCS-1 standards represented a 120-day reporting condition. On August 20, 2004, EnviroTrac, on behalf of Motiva, submitted a release notification form to MassDEP documenting the reporting condition, On August 23, 2004, MassDEP assigned RTN 4-18634. On August 20, 2004, EnviroTrac submitted a RAM Plan and release notification form following the detection of lead and PAH concentrations above RCS-1 standards during removal of a hydraulic automotive lift and components bf the former floor drain system. On November 3, 2004, EnviroTrac submitted a RAM Completion report summarizing the RAM activities, removal of the remaining hydraulic lift, floor drain trap and oil water separator. The RAM Completion report documented the completion of excavation activities. The RAM Completion also documented that approximately 28 tons of impacted soil was removed from the site to Aggregate Industries in Stoughton, Massachusetts for asphalt batch recycling in accordance with Bill of Lading procedures. One 55-gallon drum of hydraulic oil, and one 55-gallon drum of soil from the floor drain trap were transported to Northland Environmental in Providence, RI for disposal. An additional 25 gallons of groundwater was removed and transported to International Petroleum, Inc. of Wilmington, Delaware for recycling. The RAM Completion concluded that groundwater impacts in the immediate vicinity of the former oil water separator must be evaluated as well as the horizontal and vertical extent of impacted soil around the former oil water separator. On August 23, 2005, EnviroTrac submitted a Phase I Initial Site Characterization Report to the MassDEP which included a summary of soil and groundwater sampling activities conducted since completion of RAM activities in November 2004. The report provided a Numerical Ranking Score Sheet and Tier classification. EnviroTrac Tier Classified the site as a Tier II Disposal site with a NRS score of 242. On February 23, 2006, EnviroTrac submitted a Phase II Scope of Work (Phase II SOW). The purpose of the Phase II SOW was to collect, develop and evaluate sufficient information to support conclusions and opinions regarding RTN 4-18634 and to summarize specific objectives to be accomplished during the Phase II investigation. In June 2006, Motiva transferred consulting services related to RTN 4-18634 from EnviroTrac to Sovereign of Mansfield, Massachusetts. On August 23, 2007 Sovereign submitted a Phase II CSA to the MassDEP. The report documented the decrease in groundwater COC concentrations below applicable GW-2 and GW-3 standards based on data collected since 2004, The primary migration pathway for petroleum released to the subsurface is determined to be via groundwater flow. Based on an existing AUL for RTN 4-11144 which restricts access and exposure potential, the Phase II CSA report documented that there were no potential exposures to soil impacts at the disposal site. Soil vapor, surface water, or sediment impacts at the disposal site were not identified. Sovereign submitted a Phase III RAP to the MassDEP concurrently with the Phase II CSA. The selected remedial alternative (RA) was monitored natural attenuation (MNA). On August 30, 2007, Sovereign oversaw well redevelopment of MW-507 and well abandonment of MW- 501 performed by Drilex Environmental of West Boylston, Massachusetts (Drilex). Thirty gallons of impacted groundwater was generated during the redevelopment of MW-507. During development activities,it was determined that MW-507 was damaged and was subsequently abandoned. On October 17, 2007, replacement monitoring well MW-507R was installed in the vicinity of the former OWS located north of facility building. Soil samples were collected at 2-5 foot intervals utilizing a hand auger for samples at depths less than ten feet and split spoon for depths greater than 10 feet. Samples were screened in the field for headspace VOCs using a properly calibrated PID. PID readings ranged 13 Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station 54 Chauncv Street Mansfield MA from BDL to 31.4 parts per million by volume (ppmv). Soil sampled from 15-17 feet bgs was submitted to Test America for VPH, EPH, metals, and PCBs analyses. Concentrations of COCs did not exceed Method 1 S-1/GW-2/3 standards, with the exception of lead at 605 mg/kg. The soil sample containing lead at a concentration exceeding of the Method 1 standard was located at a greater depth than the 4-16 feet bgs covered by the existing AUL for RTN 4-11144. Therefore, a revised AUL under RTNs 4-18634 and 4- 11144 is necessary to restrict access to soil at depths of 4-17 feet bgs. Reason for Activity and Use Limitation The results of this Method 3 Risk Characterization indicate that conditions at the subject site pose No Significant Risk of harm to human health, safety, public welfare, and the environment within the context of 310 CMR 40.1000. Based on the detected concentration of residual lead in the 15-17 foot bgs soil sample collected from the subject property on October 17, 2007, the criteria specified in 310 CMR 40.1012(2) stipulate that an AUL is necessary to ensure that existing and future site activities and/or uses would remain consistent with the assumptions used in the MCP Method 3 Risk Characterization. Accordingly, potential land uses are being limited through the implementation of the Notice of AUL. In order to maintain a condition of No Significant Risk for future activities and uses, an AUL is required to prohibit certain future uses of the property and to restrict activities in the AUL Area such that any disruption of soil is controlled and does not render impacted soil more accessible for direct contact or ingestion by people at or near the disposal site. Activities and Uses Consistent with the AUL Opinion The AUL Opinion provides that a condition of No Significant Risk to health, safety, public welfare or the environment exists for any foreseeable period of time (pursuant to 310 CMR 40.0000) so long as any of the following activities and uses occur on the Property: W Commercial, retail, and industrial activities; (vii) Activities consistent with the above uses, including but not limited to landscaping and routine maintenance of landscaped areas, vehicular and pedestrian traffic, vehicular parking, and other non -intrusive activities which do not cause and/or result in direct contact with, disturbance of, and/or relocation of, soil currently located at depths of 4-17 feet below grade surface; (viii) Excavation associated with emergency or short term (six months or less) underground utility and/or construction work which is likely to disturb soil currently located at depths of 4-17 feet below grade surface provided that it is conducted in accordance with a Soil Management Plan and a Health and Safety Plan prepared and implemented in accordance with Obligations (i) and (if) of this Notice prior to the commencement of such activity; (ix) Activities and uses which are not identified by this Notice as being inconsistent with maintaining a condition of No Significant Risk; (x) Such other activities or uses which, in the Opinion of an LSP, shall present no greater risk of harm to health, safety, public welfare or the environment than the activities and uses set forth in this Paragraph; and (xi) Such other activities and uses not identified in Paragraph 2 as being Activities and Uses Inconsistent with the AUL. 14 Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station, 54 Chauncy Street Mansfield MA Activities and Uses Inconsistent with the AUL Opinion Activities and uses which are inconsistent with the objectives of this Notice of Activity and Use Limitation, and which, if implemented at the Property, may result in a significant risk of harm to health, safety, public welfare or the environment or in a substantial hazard, are as follows: (v) Use of the property as a residence, school, nursery, daycare, recreational area, and/or other such use at which a child's presence is likely on a frequent basis; (vi) Any short-term (six months or less) activity including, but not limited to, excavation which is likely to disturb soil currently located beneath pavement or the building slab without the prior development and implementation of a Soil Management Plan and a Health and Safety Plan in accordance with Obligations (i) and (ii) of this Notice; (vii) Any long-term (greater than six months) activity which is likely to disturb soil currently located at depths of 4-17 feet below grade surface unless such activity is first evaluated by an LSP who renders an Opinion which states that such activity is consistent with maintaining a condition of No Significant Risk; and (viii) Relocation of soil currently located"at depths of 4-17 feet below grade surface, unless such activity is first appropriately evaluated by an LSP who renders an Opinion which states that such relocation is consistent with maintaining a condition of No Significant Risk. Obligations and Conditions If applicable, obligations and/or conditions to be undertaken and/or maintained at the Property to maintain a condition of No Significant Risk as set forth in the AUL Opinion shall include the following: (iv) A Soil Management Plan must be prepared by an LSP and implemented prior to the commencement of any activity that is likely to disturb soil currently located at depths of 4-17 feet below grade surface. The Soil Management Plan must be prepared in accordance with the guidelines discussed in the Activity and Use Limitation Opinion attached hereto as Exhibit C; (v) A Health and Safety Plan must be prepared and implemented prior to the commencement of any activity that is likely to disturb soil currently located at depths of 4-17 feet below grade surface. The Health and Safety Plan must be prepared in accordance with the guidelines discussed in the Activity and Use Limitation Opinion attached hereto as Exhibit C; and (vi) The soil currently located at depths of 4-17 feet below grade surface may not be relocated, unless such activity is first appropriately evaluated by an LSP who renders an Opinion which states that such relocation is consistent with maintaining a condition of No Significant Risk. Summary and Conclusions of AUL Opinion This AUL Opinion has been prepared for implementation of a Notice of AUL for a release of oil or hazardous materials at the subject Disposal Site. Based on the reference documents (see below) and by placing an AUL at the Site, it is the opinion of the undersigned that a condition of No Significant Risk to human health and safety exists at the subject site, and that based on the Risk Characterization performed in the Phase II Assessment, the criteria of a Class A Response Action Outcome Statement have been met. 15 Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station 54 Chauncy Street Mansfield MA Reference Documents This AUL Opinion is based on the information presented in: • The Massachusetts Contingency Plan, 310 CMR 40.0000, effective October 1, 1993, as revised through March 24,2006; • "Guidance on Implementing Activity and Use Limitations, Interim Final Policy #WSC 99-300" prepared by the Massachusetts Department of Environmental Protection, May,1999; • Phase II - Comprehensive Site Assessment dated August 23, 2007 prepared by Sovereign, Phase III - Remedial Action Plan dated August 23, 2007 prepared by Sovereign, and • Class A-3.Response Action Outcome (RAO) and Method 3 Characterization, dated August 23 2008, prepared by Sovereign. LSP Certification of AUL Ouinion Name of Organization: Sovereign Consulting, Inc. LSP Name: Linda S. Falk Title: P.G., LSP, Senior Project Manager Telephone: (508)339-3200 I attest that I have personally examined and am familiar with the information contained in this submittal, including any and all documents accompanying this attestation, and in my professional judgment, this AUL opinion and form complies with the provisions of M.G.L. c. 21A, §§ 19-19J, 309 CMR, M.G.L. c. 21E, 310 CMR 40.0000, and all other laws, regulations, orders, permits, and approvals applicable to such AUL opinion. I am aware that significant penalties may result, including, but not limited to, possible fines and imprisonment, if I willfully submitormation which I know to be false, inaccurate or incomplete. Signature: Seal: Date: J f S 2009 License Number: 8624 16 Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station, 54 Chauncy Street Mansfield MA EXHIBIT D Activity and Use Limitation Opinion Form BWSC-113 17 Notice of Activity and Use Limitations - RTN 4-18634 July 15, 2008 Former Shell -Branded Service Station, 54 Chauncy Street Mansfield MA ATTACHMENT A m Massachusetts Department of Environmental Protection Bureau of Waste Site Cleanup ACTIVITY & USE LIMITATION (AUL) OPINION FORM Pursuant to 310 CMR 40.1056 & 40.1070 - 40.1084 (Subpart J) DISPOSAL SITE LOCATION: I. Disposal Site Name: Street Address: LOCATION AID CHAUNCY ST Cityrrown: MANSFIELD 4. ZIP Code: BWSC113A Release Tracking Number [4 - 18834 B. THIS FORM IS BEING USED TO: (check one) ❑✓ 1. Provide the LSP Opinion for a Notice of Activity and Use Limitation, pursuant to 310 CMR 40.1074, 2. Provide the LSP Opinion for an Evaluation of Changes in Land Uses/Activities and/or Site Conditions after a Response ❑ Action Outcome Statement, pursuant to 310 CMR 40.1080. Include BWSC113A as an attachment to BWSC113, Section A and C do not need to be completed. ❑ 3. Provide the LSP Opinion for an Amended Notice of Activity and Use Limitation, pursuant to 310 CMR 40.1081(4). ❑ 4. Provide the LSP Opinion for a Partial Termination of a Notice of Activity and Use Limitation, pursuant to 310 CMR 40.1083(3). ❑ 5. Provide the LSP Opinion for a Termination of a Notice of Activity and Use Limitation, pursuant to 310 CMR 40.1083(1)(d). ❑ 6. Provide the LSP Opinion for a Grant of Environmental Restriction, pursuant to 310 CMR 40.1071. ❑ 7. Provide the LSP Opinion for an Amendment of a Grant of Environmental Restriction, pursuant to 310 CMR 40.1081(3). [] 8. Provide the LSP Opinion for a Partial Release of a Grant of Environmental Restriction, pursuant to 310 CMR 40.1083(2). ❑ 9. Provide the LSP Opinion for a Release of a Grant of Environmental Restriction, pursuant to 310 CMR 40.1083(1)(c). ❑ 10. Provide the LSP Opinion for a Confirmatory Activity and Use Limitation, pursuant to 310 CMR 40.1085(4). (Unless otherwise noted above, all sections of this form (BWSC113A) must be completely filled out, printed, stamped, signed with black ink and attached as an exhibit to the AUL Document to be recorded and/or registered with the Registry of Deeds and/or Land Registration Office.) AUL INFORMATION: Is the address of the property subject to ALL different from the disposal site address listed above? ❑✓ a. No ❑ b. Yes If yes, then fill out address section below. Street Address: Cilyrrown: 4. ZIP Code: r<evisea: ubtznzuu3 Page 1 of Massachusetts Department of Environmental Protection Bureau of Waste Site Cleanup BWSC113A ACTIVITY & USE LIMITATION (AUL) OPINION FORM Release Tracking Number Pursuant to 310 CMR 40.1056 & 40,1070 - 40.1084 (Subpart J) a - 18634 LSP SIGNATURE AND STAMP: I attest under the pains and penalties of perjury that I have personally examined and am familiar with this transmittal form, including any and all documents accompanying this submittal. In my professional opinion and judgment based upon application of (I) the standard of care in 309 CMR 4.02(1), (if) the applicable provisions of 309 CMR 4.02(2) and (3), and 309 CMR4.03(2), and (Ili) the provisions of 309 CMR 4.03(3), to the best of my knowledge, information and belief, > if Section B indicates that a Notice of Activity and Use Limitation is being registered and/orrecorded, the Activity and Use Limitation that is the subject of this submittal (i) is being provided in accordance with the applicable provisions of M.G.L. c. 21 E and 310 CMR 40.0000 and (it) complies with 310 CMR 40.1074; > if Section B indicates that an Evaluation of Changes in Land Uses/Activities and/or Site Conditions after a Response Action Outcome Statement Is being submitted, this evaluation was developed in accordance with the applicable provisions of M.G.L. c. 21E and 310 CMR 40,0000 and (ii) complies with 310 CMR 40.1080; > If Section B indicates that an Amended Notice of Activity and Use Limitation orAmendment to a Grant of Environmental Restriction is being registered and/or recorded, the Activity and Use Limitation that Is the subject of this submittal(!) is being provided in accordance with the applicable provisions of M.G.L. c. 21 E and 310 CMR 40.0000 and (it) complies with 40.1081; > if Section B Indicates that a Termination or a Partial Termination of Notice of Activity and Use Limitation, or a Release or Partial Release of a Grant of Environmental Restriction is being registered and(or recorded, the Activity and Use Limitation that is the subject of this submittal (1) Is being provided in accordance with the applicable provisions of M.G.L. c. 21 E and 310 CMR 40.0000 and (it) complies with 310 CMR 40.1083; > if Section B indicates that a Grant of Environmental Restriction is being registered and/or recorded, the Activity and Use Limitation that Is the subject of this submittal (1) is being provided in accordance with the applicable provisions of M.G.L. c. 21E and 310 CMR 40.0000 and (11) complies with 310 CMR 40.1071: > if Section S indicates that a Confirmatory Activity and Use Limitation is being registered and/or recorded, the Activity and Use Limitation that is the subject of this submittal (i) is being provided in accordance with the applicable provisions of M.G.L. c. 21 E and 310 CMR 40.0000 and (it) complies with 310 CMR 40.1085(4); 1 am aware that significant penalties may result, including, but not limited to, possible fines and imprisonment, if I submit information which I know to be false, inaccurate or materially Incomplete. LSP #: 8824 FlrstName: ILINDAS 3. Last Name: FALK Telephone: (508) 339-3200 1 5. Ext.: = 6. FAX: (508) 339-3248 Signature: L =J Z� I 8. Dale: yi, LSP Stamp: RUvlbuu. UWz I14uuo Page 2 of 2 End of Document