HomeMy WebLinkAboutSeptic Pumping Slip - 98 MARIAN DRIVE 3/16/2016 Commonwealth of Massachusetts
City/Town of _NORTH AN DOVE RMASSAC H US ETTS
Pumping System r
r` Form 4
DEP has provided this form for use by local wards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority _
,fin r
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use 98 MARIAN DRIVE
i
only the tab key Address
to move your N. ANDOVER MA 01845
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
t�s DWAYNE & AMY BAILEY
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping cccrd
_
1. Date of Pumping Date 8/15/06 2. Quantity Pumped: 2000
Gallons
3. Type of system: ❑ Cesspool(s) FX-] S tic TCHAMBER F-1 Tight Tank
PURP❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? ® Yes ❑ No
5. Condition of System:
GOOD
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
FITCHBURG TREATMENT PLANT
9/15/06 _
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System,Pumping Record-Page 1 of 1
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SY 1 M/PUtvLNR RECORD
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SYSTEM OWNER& ADDRESS �
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DATE OF MPIA1c ; UANTITY PUMPED:
SOPtic "Carak: NO YES
NATURE OF SERVICE:
013SERVA'rioNs;
GOOD CONDITION FULLTO COVER
HEAVY O SE �
. BAFFLES IN PLACE,
ROOTS I-EACF FPL,p RtJN13ACK
6XCESSJVE SOLIDS,_.__, A FLOODED
SOLID CARRYOVER,.. ......OTHER EXPLAIN
Systom Pumpod by )
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L UMMENTb,
CUNTENTS TFLANSFI�RRED TQ 1