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145 Title 5 11-28-17 Commonwealth of Massachusetts . * u, :Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1/44:: 145 Chesterfield Road Property Address Sue and Kevin Costa etermsten N per's Name rostered for Leeds MA 01053 11/28/2017 eYery Dee.' C1tyfro ml Mete Zip Code Date of Inepecibn Inspection results must be submitted on this form.Inspection fonns may not be altered In any way. Please see completeness checklist at the end of the form. When filling A. General Information one fume an me computer. 1. Inspector use only the tab key to Marcus Millett more your Name of Inspector poor-do not use the return Homestead Engineering Inc. key. Company Name IM ... 1664 Cape St. Company Ado... Williamsburg MA 01096 Dail ClyiToam sate zpcoe. 413-628-4533 SI-13748 Telephone Minter license Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 6(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes 0 Fails j/❑/j�N,_eeed,dsFurtherr Evaluation by the Local Approving Authority * tAy November 28, 2017 Inspector's Moisture Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner aid copies sent to the buyer, if applicable, and the approving authority. • ""This report only describes conditions at the time of Inspection and under the conditions of use at that time.This Inspection does not address how the system will perform in the future under the same or different conditions of use. Ms•vie The 5ancta InscOelbri Fa ee..oe.s.wp.Disponi awe,•Pep I an 14 Commonwealth of Massachusetts . - - f, Title 5 Official Inspection Form eSubsurface Sewage Disposal System Form-Not for Voluntary Assessments ,‘ 145 Chesterfield Road Properly Address Om « Sue and Kevin Costa Inramallon le Oxeere Name required for Leeds MA 01053 11/28/2017 seen sso. csfam n eats Zip code Date a kopecmn B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ® I have not found any information that indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated we Indicated below. Comments Leaching system was not excavated a) System Condldonaly Passes: O One or more system components as described in the'Conditional Pass'section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for yes', "no"or"not determined° (Y, N, ND)for the following statements. If'not determined;please explain, The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection it it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ND(Explain below): ❑ Pump Chamber pumpslalarms not operational.System will pass with Board of Health approval if pumpsfalarms are repaired. t.&e•sre 11105a 1,, - Paw Otsi&w&es .CE •I;Worn•Pap 2 017 t Commonwealth of Massachusetts • . ,. * v e/ Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 145 Chesterfield Road ProperNAddrees OmerSue and Kevin Costa tnformaIion Is Owner's Name required for Leeds MA 01053 11/28/2017 every Page. Ctty?own State Lp Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont): 0 Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑Y ❑N ❑ND(Explain below): ❑ obstruction is removed ❑V ❑N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑Y ❑N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ V ❑ N ❑ ND(Explain below): ❑ obstruction is removed 0 V 0 N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines In accordance with 310 CMR 15.303(1Xb)that the system Is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy isiwithin 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh eM.16 ale 5Ca'Yllnepatlm Fenn:6uba m Seng*Petrosa When•PN.30117 • LIrk Commonwealth of Massachusetts " Title 5 Official Inspection Form b Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments , !S• 145 Chesterfield Road Properly Address Own « Sue and Kevin Costa information's Owner's Name required for even,page Leeds MA 01053 11/28/2017 city/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, If any)determines that the system Is functioning In a manner that protects the public health,safety and environment ❑ The system has a septic tank and soil absorption system (SM)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SM and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well•. Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria am triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must Indicate"Yes"or"No"to each of the following for all Inspections: Yes No ❑ HBackup of sewage into facility or system component due to overloaded or dogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than.14 0 r. day flow Me•8/111 lass Official Inspection Fm,[Subsurface Stags q¢vY%vi m•Fags 4tl t] , 321,, Commonwealth of Massachusetts • t Title 5 Official Inspection Form ■ � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '', * it ,. 145 Chesterfield Road Property Addess Donau Sue and Kevin Costa Information b Owners Name required for Leeds MA 01053 11/28/2017 every page. Cay/Town State Zip Code Date of Inspection B. Certification (cont) Yes No ❑ ® Re quired Np bpitimes of ping more than 44 times in the last year NOT due to clogged or obstructed pi ❑ ® My portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® My portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ (21 My portion of a SAS,cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes If the well water analysts, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria am triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ Z The system is a cesspool serving a facility with a design flow of 2000 gpd-10,000 gpd. ❑ ® The system falls. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either eyes'or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply D ® the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes°in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section I)shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Sas.SMB The Official Inspection Form:eawear Swage gep"rl Sybm•page 5w 17 14 Commonwealth of Massachusetts . wl Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 145 Chesterfield Road Property Mdrew Sue and Kevin Costa Owner Informeeon Y Owner's Name regiked br Leeds MA 01053 11/28/2017 every page. atyrrown State Zap Code Data of osimo ton C. Checklist Check if the following have been done. You must indicate"yes"or'no'as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health O ® Were any of the system Components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two-week period? D ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as-built plans of the system obtained and examined?(If they were not available note as N/Al ® 0 Was the facility or dwelling inspected for signs of sewage beck up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® 0 Existing information. For example,a plan at the Board of Health. D ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D.System Information Residential Flow Conditions: Number of unknown Number of bedrooms 3 bedrooms(design): (actual): DESIGN ft*based on 310 CMR 15.203(for example: 110 gpd x#of 330+ gpd bedrooms): SYw•W16 1W 5CMJinga..,Form:Subsurface SWOP Wpo IayOm• needn Commonwealth of Massachusetts . •lft! 1111 _` Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments • 145 Chesterfield Road Properly address Omer Sue and Kevin Costa hfmmeyon is Owners Name required kr Leeds MA 01053 11/28/2017 every per. Cferovm State Zip cods Oeta ofInspeelbn D. System Information Description: 900-gallon septic tank and a gravel filled leach pit. Number of current residents: 2 Does residence have a garbage grinder? ® Yes 0 No Is laundry on a separate sewage system?(Include laundry system ❑ Yes ® No Inspection information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, ifavailable(last 2 yews usage(gpd)): 58 Detail: 2/10/17 to 5/9/17 used 800 ccf Sump pump? 0 Yes ® No Last date of occupancy: continuous Commerclal lndustdal Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): "mons per day(ypd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? 0 Yes 0 No Industrial waste holding tank present? ❑ Yes 0 No Non-sanitary waste discharged to the Title 5 system? 0 Yes ❑ No Water meter readings, if available: ee..floe 7_•5 OfIreliteaw- raw Subiudece Swop 1:1111Mel5) se•nw 7an , I Commonwealth of Massachusetts . • w, „ Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form-Not for Voluntmy Assessments 145 Chesterfield Road Property Mean Omer Sue and Kevin Costa Inkrmetlan b Own ere Name required for Leeds MA 01053 11/28/2017 ovary paps, City/Town State 2Ip Code Date of Inepectlon D. System Information (cont) Lest date of ocapancy/use: Date Other(describe below): General Information Pumping Records: Source of Information: Pumped task August 2016 Was system pumped as part of the inspection? ❑Yes ® No If yes, volume pumped: owns How was quantity pumped determined? Reason for pumping: type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool O Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(ff yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ light tank.Attach a copy of the DEP approval. ❑ Other(describe): Lam•NIB 11114 5 Mil Impale,Form:&Aminawap EYpooll System•Pay s 0117 . 14 Commonwealth of Massachusetts . ' wi .'Title 5 Official Inspection Form 11/44, -1 ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 145 Chesterfield Road Property Address owner Sue and Kevin Costa nbrnmtion fe Owner's Name 'wind f" Leeds MA 01053 11/28/2017 every Page. City/Town state Zip Code Dab of Inspection D. System Information (cont) Approximate age of all components,date installed(if known)and source of information: Septic said to be built in 1948 Were sewage odors detected when arriving at the site? ❑Yes ® No Building Sewer(locate on site plan): Depth below grade: 4.5 average bet Material of construction: i4 cast iron ❑40 PVC li other(explain): Orangeburg pipe Distance from private water supply well or suction 24 line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): No problems seen. Under basement floor slab. Measurement is between water inlet and sewer outlet in basement. Septic Tank(locate on site plan): Depth below grade: 4.1 average hit Material of construction: ®concrete ❑metal ❑fiberglass ❑polyethylene 0 other(explain) Concrete septic tank. About 900 gallons nominal. If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No certificate) Dimensions: 48" wide, 88" long, 65" height Sludge depth: 2" aka•618 TM 5 OaW keaeMe Fa Suburbs asap OWNS%lbw•Pop a S1w . t:., Commonwealth of Massachusetts . u Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 145 Chesterfield Road Rommammm amen Sue and Kevin Costa information is Owners Name required far Leeds MA 01053 11/28/2017 every page. atiyamm Stam np Dode Dar of Impaction D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee 26^ or baffle Scum thickness 1 Distance from top of scum to top of outlet tee or 6^ baffle Distance from bottom of scum to bottom of outlet 1e" tee or baffle How were dimensions determined? calculated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 900—gallon septic tank. Removable baffle type. Outlet baffle was replaced in 1996. Unconsolidated gravel soils precluded extensive excavation to evaluate both tank ends. Riser to the surface over center cover for maintenance. Grease Trap(locate on site plan): Depth below grade: feat Material of construction: 0 concrete 0 metal 0 fiberglass 0 polyethylene 0 other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: am 14..11 Tr SGSIY Samoa Form:Submitsa Saw.pawl ennen•Page 10a1> . 14 Commonwealth of Massachusetts • s,, !i Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .. . ,.. 145 Chesterfield Road Propwty Addreee Q,11re Sue and Kevin Costa Flonnauen k ownele Naas fOquirISfor Leeds MA 01053 11/28/2017 oven Pepe. Ctiyrtown Stere Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: El concrete 0 metal 0 fiberglass 0 polyethylene 0 other(explain): Dimensions: Capacity: gallons Design Flow: gallons par day Alarm present: 0 Yes 0 No Alarm level: Alarm In waking order: 0 Yes 0 No Date of lest pumping: pate Comments(condition of alarm and float switches, etc): Made copy of current pumping contract(required). Is copy attached? 0 Yes 0 No lea•me TM IS aeoelInpWM Fain:sesame aw'ape awn Neem•Pepe 11 a 17 • % Commonwealth of Massachusetts . „ • s r Title 5 Official Inspection Form w ' Subsurface Sewage Disposal System Form•Not for Voluntary Assessments - `` 145 Chesterfield Road Property Mnfto Owner Sue and Kevin Costa Information IS Dyne s Name f°4ikedbrLeeds MA 01053 11/28/2017 owl Par. Clty/To•n Stab tip Code Date of Inspection D. System Information (cont) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert None in system Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order. 0 Yes 0 No Alarms in working order: 0 Yes 9 No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): • If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: w.•we The 5O SI,apdonram:&tsac.eowpwl Wein•No 124017 .a:.. Commonwealth of Massachusetts . • ."Title 5 Official Inspection Form • t 1, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments !' 145 Chesterfield Road Property Address Owner Sue and Kevin Costa Inforlllaeen le Deers Name required Por Leeds MA 01053 11/28/2017 awry peps. avian an Zip Code Deb of Inspection D. System Information (cont.) Type: ❑ leaching pits number. one ❑ leaching chambers number ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typeiname of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): No surface issues seen. Earlier inspection report defined size and location. No open-able components. Made with large volume of washed stone in a pit excavation. Cesspools(cesspool must be pcanped as part of inspection)(locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow 0 Yes 0 No aa•s96 711•5OII Ii prddrn For,:sWertu 8s.. ayl WOW.pyaa 13d17 Commonwealth of Massachusetts . w. Title 5 Official Inspection Form w ,n Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments y . 145 Chesterfield Road Property Address owner Sue and Kevin Costa bronnatlon la O*n&s Name fepiked for Leeds MA 01053 11/28/2017 eyed,Page. ClryRown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): sero•e16 Tile a011dNlmp lens Fa,:Bubo'face Sewage rapaa&Ieem•Page 14d 17 A , Commonwealth of Massachusetts 5 _ -�y Title 5 Official Inspection Form • b 1 J Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •�"+.; 145 Chesterfield Road Property Address owner Sue and Kevin Costa information is Owners Name required for Leeds MA 01053 11/28/2017 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately ens•&16 The sol lel Inspection Form:subsWace Sewage Disposal System-Page 15a 17 Commonwealth of Massachusetts i e Title 5 Official Inspection Form 7'911—.1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •'q.,.7, 145 Chesterfield Road Property Address owner Sue and Kevin Costa information is Owner's Name required for Leeds MA 01053 11/28/2017 every page City/Town City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 10+ Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date • Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Site immediately surrounded by steep drop-off of approximately 20 ft. No surface water seen in vicinity. Glacial outwash soils are extensively drained. Saw roots to 5 feet below grade. Circ•6116 Title 5 Oseii dap tion Form.Subsurface 6ewge Wpovl SpMm•Page 16 U 11 Commonwealth of Massachusetts 1, srTitle 5 Official Inspection Form _--�`- ;.,T/Title Subsurface Sewage Disposal System Form •Not for Voluntary Assessments -r- aAm�' 145 Chesterfield Road Property Address Owner Sue and Kevin Costa information is Owners Name required for Leeds MA 01053 11/28/2017 every page. City/Town state Zip Code Date of Inspection Before filing this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file lens•6/16 Tile s Official Inspection Form.Subsurface Sewage Deposal System•Page 17 of 17 COMMENTS: Recommend pumping on a 3 to 4 year schedule. Also, a copy of this plan posted in the basement/utility area would keep this information accessible in future years for maintenance. 12' / / htiiih Septic Tank Site constructed gravel leaching area, reported size and location ii NORTH House Outline Town water in IP' As-Built Drawing Date: Owner HOMESTEAD INC. Existing Septic System 11/28/2017 Sue and Kevin Costa maks. tIGYµ \ Thomas S. Leue R.S. Scale: 1 : 20' Revision Date: 145 Chesteffield R•-d/ , „ �2 - 1664 Cape St. a, Williamsburg,MA 01096 Except as Noted Leeds MA 01053 \ ii, [413162845n