HomeMy WebLinkAboutDORA #2 LT 16Dora #2
Lot 16
#014-251-33
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: _________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
PERMIT NO.
DEF'FIRTMENT ,. HEFILTFt F~F,tD EN',,,'IRONMENT~.L ..OTECTION
8;:.':5 "' L '" STREET., F~NC:HORRGE., ~K. 9950±
26,4- 47:..70
IL.~EILL_ F'F:F.".~'-I ~ T
FIPF'L. I CI::tNT '1". S'T'ENFIF,:T CONS'T.
L. OC:RT I ON
L. EGRL L.±6 [:,ORFI 2
,:.1. 20 W I L L I N FI C I R C:L E
LOT SIZE
20000 $(,.".!U~RE FEET
MINIMUM DISTRNCE BETWEEN R WELL. RND RNV ON-SITE SEWRGE [:,ISPOSRL. S'~.'E;'TEP1 IS
±00 FEET FOR R PRIVRTE WELL. OR t50 TO 200 FEET FROM Ft F'UBLIC WELL DEPENDING
UPON THE "F'T'PE OF' PUBLIC NELL
MINIMUM [:,ISTRNCE: FROM R PRIVRTE WELL TO R PRI","RTE SEWER LINE !S 25 FEET F~N[:'
TO FI COMMLINITY SEWER L. INE IS ~5 FEE'F.
WEL. L. L. OGS RRE REQUIRE[:, RN[:, MUS]' BE RETURNE[:, TO THE [:,EPRRTMENT I.,.IITHIN
OF' TFtE NEL. L COMPLETION
OTFIER REQLIIREMENTS MR¥ RPPL¥. SPECIFICRTIONS RN[:, CONSTRUCTION [:,IRGRF~MS FIRE
Iq',,,'FIILFIBLE TO INSURE PROPER INSTRLLRTION.
I C:EF.':T I F"r' THRT
i: I l'~M FRMIL. IRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND NEL. LS FIS ~:ET
;~;':i'~':'~ ~" ,.,~ ~= ;.~,~ '"'~~ ~.':"-~ ~; ~},i,;~, ~~,,::~. ~.~ ..~, ~.,~ ,::o ~:,~.?..
RFFI...ICFtN~. lT. STEWRR]" CONST.
V4. 0
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 014-251-33
Legal description DORA #2 LT 16
Site address 8550 Rosalind St Anchorage
Current property owner(s) Crutchfield
Expiration Date:
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
Original Certificate Date: 3// L 202
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory XX
Other
COSA Approval_June 2022
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 014-251-33
Complete legal description DORA #2 LOT 16
Location (site address) 8550 ROSALIND STREET, ANCHORAGE, AK 99507
Current property owner(s) BRITTANY M. CRUTCHFIELD Day phone
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
3. TYPE OF WATER SUPPLY: ® Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ® Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ c2l
0 Waiver Fee $
Date of Payment 3/ 16169.3 Date of Payment
COSA # (330_�;O t lbs '�) Waiver #
-#-oio`1V
COSA Applicalion.doc
COSA Checklist WELL ONLY.docx
COSA Checklist
Legal Description: DORA #2 LOT 16 Parcel ID: 014-251-33
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled 4/28/1981 Total depth 113 ft
Cased to 113 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 3/7/2023
Static water level at beginning of test 38 ft.
Well production at time of test 3.1 gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate 2.88 mg/L Nitrate less than MRL (ND)
Arsenic 67.9 ug/L Arsenic less than MRL (ND)
Collected by
Date 3/7/2023
Comments: Recommend POU water treatment at kitchen sink for drinking water if desired to address higher arsenic or
other water quality levels. Well drilled per code & separations met at time of installation. Attached AWWU connect card &
aerial. Private sewer service line connects to main sewer line on the opposite side of the house from the well.
B. TANK DATA – PUBLIC SEWER
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA - PUBLIC SEWER
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes go to bottom of effective.
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Adequacy test date
Results Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
Comments/Deficiencies:
COSA Checklist WELL ONLY.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No NA ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No NA ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No *85+/- ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
*Well drilled prior to public sewer installation and met code & separations at that time. Per existing MOA files
& attached sketch of located MH and submitted AWWU docs.
G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 3/9/2023
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
3/16/2023
MU6 CIP UTY OF ANCHOR GE
DEVELOPMENT SERVICES DEPARTMENT
On -Site Water and Wastewater Section
www.muni.org/onsite
f ''d 907-343-7904
Fax: 343-7997
Arsenic Advisory
Certificate of On -Site Systems Approval # OSC231052
Subdivision: Dora #2, Block: , Lot: 16
A water sample revealed an arsenic concentration of 67.9 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Information on arsenic is available from the On -Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, l verify that my, investigation,
based on procedures ,outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the -on-site rwater supply -and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and front my investigation and inspection, the on-site water
supply and/or wastewater disposal system'is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect:at the time of installation.
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 11/09/2015
..Engineer's Comments: This investigation was completed in with ADEC and MOA regulations. The assessment of the condition
of the well and septic applies only to the conditions as of.the day tested. The pow and absorption rates may change due to subsurface
conditions that may not be observed from the Surface,` changes inland use; local soil characteristics, groundwater levels that may fluctuate -
during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are -
subject tothesevarious and dynamic characteristics and are outside the control of the
evaluator of the well and. septic system. Therefore, - - -
ArcTerra can not give. any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen i OF AL\
encroachments, deficiencies or discrepancies exist. //-
_* 9 TH
6: DSD GNATURE `
System #1 Approved for bedrooms. r, NEI 7 16 e $
System #2 Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
ta�(tU(fir,f�
...Q "y OF qN",e
ON-SITE
o
WATER AND rt
PROGRAM
SERVI
By: \� vvll �� Original Certificate Date: �- — 1J
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval'(COSA) based only
upon the representations given in patagraph 5 by an independent professional civil engineer registered in the State. of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work. -
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory _ Other
COSA blue sheet 10-10.12.dac
q
If more than 1 septic system is on the lot:
COSA Checklist # _of _
Structure served by this system _
Certificate of On -Site Systems Approval Checklist
Legal Description: DORA#2 LOT 16 Parcel ID: 014.251.33
A. WELL DATA
Well type PRVT If A, B, or C provide PWSID # _ Well Log (Y/N) Y
Date completed 4/18/1981 Sanitary seal (Y/N) y Wires properly protected (Y/N) Y
Total depth 113 ft. Cased to 113 ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 4/28/1981 10/30/2015
Static water level 48 ft.
Well production 13 g:p.m.
WATER SAMPLE RESULTS:
Coliform NEG oolonies/100 mL Nitrate ND mg/L
Arsenic: 59 ug/L Date of sample: 10/30/2015
B. SEPTICIHOLDING TANK DATA — PUBLIC SEWER
Tank Type/Material
Tank size _ gal. Number of Compartments
Foundation cleanout (Y/N) Depression over tank (Y/N)
ft.
9—
p.m-
Collected by: ARCTERRA
Date installed
Cleanouts(Y/N)
High water alarm (YIN)
Date of pumping ' ' Pumper
C. ABSORPTION FIELD DATA
Date installed_ Soil rating (g.p.d.W or fe/bdrm) System tvoe
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption area Je Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) _ For bedrooms
Fluid depth in absorption field before test — in. Water added_gal. New depth_ in.
Elapsed Time: _min. Final fluid depth _ in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at _ in.
Datum
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot NA
Size in gallons
"Pump off' level at —in.
Cycles tested
Absorption field on lot NA
Public sewer main 75'+
Sewer /septic service tine 254
Animal containment areas 501+
SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation Property line _
Water main Water service line
Wells on adjacent lots
ABSORPTION FIELD ON LOT TO: PUBLIC SEWER
Property line Building foundation
Water Service line Surface water
Curtain drain Wells on adjacent lots
F. COMMENTS
Manhole/Access (Y/N) _
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots NA
On adjacent lots NA
Public sewer manhole/cleanout '85'+
Holding tank NA
Manure/animal excrete storage areas 1004
Absorption
Surface water
Water main
Driveway, parkingfvehicle storage
f+n9 Cade reg&1,0'4"*Y1*s�a,G�`�Jevly.►••�•
G. ENGINEER'S CERTIFICATION a4.� r'/ j�i� OF
I certify that I have determined through field inspections and review of LH -77
Municipal records that the above systems are in conformance with MOA
COSA guidelines in effect on this date.
Engineer's Printed Name KENNETH M. DUFFUS
Date 11/09/2015
COSA canary sheer2-6-15.doc
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Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
Arsenic Advisory
Certificate of On -Site Systems Approval # OSC151624
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Lot 16 of Dora #2
Subdivision. This inspection revealed an arsenic concentration of 59
micrograms per liter (ug/L) for the property's well water sample. The
Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems.
While private wells are not subject to this regulation, EPA standards are
based on existing health information and can therefore be used to gauge the
relative quality of water from private wells. Information on arsenic is
available from the On -Site Water and Wastewater Program website
(www.muni.or /off nsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
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UNDER NO CIRCUMSTANCES SHOULD AN AS-BWLT'BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES,
THE SURVEYOR TAKES RESPONSIBIUTY I-OR THE INITIAL. TRANSACTION ONLY AND ASSUMES F94ANCIAL: LIABILITY ONLY FOR THE DOST OF THE SURVEY.
USIED DISTANCES PREVAIL OVER SCAUNG. REPRODUCTION MAY CAUSE ERRORS IN SCALE.
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LOT PLANS & LOT' SURVEYS ...NOTE;.
1T IS THE RESPONS€BIUTY OF T41E BUILDER OR DIMMER, PRIOR TO I ONLY THOSE. IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE
CONSTRUCTION. T43 VERt1'Y PROPOSED BUILDING GRADE REi.ATVE I SHOWN, FENCES. 'MOLLS, SEPTIC CLEANOUT$ SIOEWALNS. DRIVEWAYS.
TO FINISHED GRADE ANU UTIUTY CONNECTIONS AND TO DETERMINE ETC„ ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW
THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED,
WHICH: DO NOT APPEAR ON T44E RECORDED SUBDIVISION PLAT. ALL CUSITANCaE'$ ARE RECORD UNLESS OTHERWISE NOTED.
SURVEY CERTIFICATION
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OF" �jj"�"�►�, Robert E. JohnsJr. & Assoc.
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~ I · ~ DATE RECEIVED
., INSPECTION APPOINTMENTS
~IM~: ~ ~'~ TIME TIME '
DATE DATE DATE
,N PECTOR ,NSPECTOR NSPECTO
~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE~N~ENT/~L preP'fEeT ON
DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proceed. Please allow ten (10) days for processing,
MAI LING ADDRESS -
PROPERTY RESIDENT (If different from above) PHONE
'2. BUYER ' ~/~ ~ ~ ' PHONE
, , .
MAILINGA DRESS ~ ~ /
3. LENDING INSTITUTION - . ~ __ I PHONE
MAILING ADDRESS '
4. REALTOR/AGENT ~~ ' ~ .... I PH~N~' '
MAI LING ADDRESS ~ ,.
6, TYPEOF RESIDENCE - NUMBER'OF,BEDROOM~ '
One ~ Four ~ Other
SINGLE FAMILY ~ Two ~ Five
[] MULTIPLE FAMILY
7. WATE. R ~UPPLY
'1~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTI LITY
8. SEWAGE DISPOSAL ~YSTEM
[] INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
[] Six
[] Three
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available,)
YEAR ON-SITE SYSTEM WAS INSTALLED,
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
THIS SIDE FOR OFFICIAL USE ONLY
NUMBER OF BEDROOMS
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SIX
[] OTHER
2. WATER SUPPLY ;
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTI LITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] I NDIVI DUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank.
Size: If Tank is homemade
give dimensions:
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
MATERIAL
Septic/Holding Tank IAbsorption Area
I
ISewer Line
INearest Lot Line
5. c~)MMENTS
~."-APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE
72-010 (Rev, 6/79)
No.
TAX CODE
PRO PERTY:
Name
-W
MUNICIPALITY OF ANCHORAGE —SEWER UTILITY
Plat No,-- Subd.
Residential 15D Commerial El
Address��
Industr'lal ❑
e7 5A /-.9Mp
No. of units
%T AcctNo S�-o0/9-89D
Lot--- /6 Block
CONNECT
Main Tap On Property ❑ Permit No. — 0.2 - e. Size `� Type e -�
Drawing No. Size Malin Type Depth at Connect
Insulation Q Cleanouts Type
Connect Agent 1-4 _Inspector 4,:4 APIQv 0.jfejVZi!F' Date 7 ' d02? —R/
Comments ST7woci7-,-0,00ys00,� v- i V 1.5 �
d &- C"? ee
Connect Location
E 00�G
ASSESSMENTS:
L.I.D. No. Private Dev. No,, subd. Agreement ❑ No.
Sewer Agreement ❑ No. P.T.E. ❑ Roll No.
L ItZ5I#
Positive El Negative ❑ N.S.A. ❑ Date
Page No. W. H. No. Billing Cycle
Tested B y
Comments
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