Loading...
HomeMy WebLinkAboutTitle V Inspection Report - 73 RIVERVIEW STREET 6/13/2009 Commonwealth of Massachusetts - Title 5 official Inspection Form JUN . 0 u Subsurface Sewage Disposal System Form- Not for Voluntary Assess �ts V t Ate DO K&k,,Tf,1 DEPARTMENT 4:P1 W, Property Address Owner Ownef s Name Q informatics is �',. '4,v,�,�s • 0 .�. 0r?Y / / required for G''�''` every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Ida✓✓ ,✓ e�f�.�f 0"V Name of Inspector Company Name LL Company Address City/Town State Zip Code 5-0 S;'� r' )- S' Telephone Number 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 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature 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 and copies stint 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. 15ins•09/08 1 Itle 5 Official Inspection Eo=Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J _ Property Address a^A$'^('&A^✓ 170k-f R-S —Owner Owner's Name _._.. information is required for t�h /-}-/[i vot/1Q/ 104, 019 every page, CityfTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: WI-'have not found any information which 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 are indicated below. Comments: f C �✓.� �I `.� J` h.2.� lr�i r 6 —F -�f �°'�/"` f 1' rJ �✓' (slit cl.c�' /1/C��'1'K�.( �..a<"l [Ul✓ Cvc4�t�jl`[c�y.� �r �t`.T j 13) System Conditionally Passes: ❑ 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(w ther metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration tank failure is imminent. System will pass inspection if the existing tank is replaced with a comp ng septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structur y sound, leaking and " a Certt Icate of Compliance indicating th tank is less than 20 y rs old is a ilable. ❑ Y ❑ N ND(Explain bet ): 15ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments W me- 4/ S- Property Address aM,t/f C1;0,✓ /-f4J' Owner Owner's Name information is < .required for � ytT� /!/ !/�� /¢ 01 P, + !l lG? every page. City/Town State Zip Code Date of inspection B. Certification (Cont.) B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below), ❑ The system re !red pu ing mor han 4 times a ye due to broken or bstructed pi (s).The system will p s inspec' n if(wit approval of the and of Health): ❑ br ken pipe(s are rep ced Y ❑ N ❑ D( ain belo ): ❑ obstruction i rem ed ❑ Y ❑ N ND(Explain bel w): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the B of Health in order to determine if the system is failing to protect public health, safety or a environme t. 1. System will pass unle Board of Health termines in cordance th 10 CMR 15.303(1)(b)that the to is not functi fng in a man which wil rote public health, safety and the env' nme ❑ Cess of or privy s within feet of a surfa water ❑ esspool or pri is hin 50 feet of a b rdering vegeta d wetland or salt marsh 15ins•09108 Title 5 Official Inspection Form;Subsurface Sewage- isposal System•Page 3 of V Commonwealth of Massachusetts VVTitle 5 official Inspection Form � Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner Owner's Name information is required for 141411-Ty_ every page. CitylTown State Zip Code bate 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 (SAS)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 SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SA ' within 50 fee a private water supply well. ❑ The system has a septic tank and SAS and the SAS i ess than 100 fe but 50 feet or more from a private water supply well". Method used to deter ' e distance: k" This system p ses if the ell water analy ' , performed at a EP certified labor ory, for c liform bacteria indica s absent a the presence f ammonia nitro g and nitrate nitro g n is equa o or less than 5 p , provided t at no other f i re criteria are tri ered.A copy of th an m st be attached to is form. 3. Oth D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged 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 clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than'/ day flow t5ins-09108 Title 5 Gfficial Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address e✓'C"L� ! ova e1 Owner Owner's Name information is �y p --required for /f/y1_I't, /7/�cl eve", every page. CitylTown State Zip Code Dale of inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of tunes pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ F�_Ir/ Any 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. ❑ 2 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet P P vY 9 from a private water supply well with no acceptable water quality analysis. [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 are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ i,J,/ The system fails. 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"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the syste i in 400 feet of a surface Inking water ply ❑ ❑ th ystem is w' hin 200 feet of a t ' utary to a su ce drinking wate u ly ❑ ❑ the system is ocated in a nitr en sensitive a (Interim Wellhe d Prot ction Area—IWP or a mappe one II of a pu is water supply we If you have swered "yes"to y question ' Section E the stem Is considered significa threat, or answe d "yes"in Section above th arge system h failed.The owner or perator of ny large syste onsidered a signific t threat nder Section E failed under Section shall upgra a the syst in accordance with 3 0 C 15.304.The syst owner should con ct the appropr' to re onal office of the Departm t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Usposal system•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments y� E Property Address Owner Owners Name information is required for ef Z�!v -7-A r>CIPi' _ 4A o lg�r every page. City[Town State Zip Code Date of inspection 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 ❑ L`7 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? ❑ 2111" 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 NIA) ❑ Was the facility or dwelling inspected for signs of sewage back up?, L� ❑ Was the site inspected for signs of break out? L� ❑ Were all system components, excluding the SAS, located on site? Lf ❑ 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? p, ❑ 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: ❑ Existing information. For example, a plan at the Board of Health. ❑ 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 bedrooms(design):' — — Number of bedrooms (actual): ©ESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•69108 Title 5 Official Inspection Farm:Subsurface Sewage disposal Warn•Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Naive information is / required for //�,__ G±�/�� �✓�� _ IAL - every page. City/Town State Zip Code Dale of Inspection D. System Information Description: V f� f Number of current residents: Does residence have a garbage grinder? ❑ Yes I" No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes C` No Laundry system inspected? 0 Yes ❑ No Seasonaluse? ❑ Yes 2/"No Water meter readings, if available(last 2 years usage(gpd)): Detail: Q t°✓�✓ fvcz��c., !"f�.�� tJ� i-'Gt.til rc( �t✓� rl' Lim ca FT 41,T_ T(lzle d,, Sump pump? ❑ Yes No Last date of occupancy: 6—f Date �� Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gall perday{gp Basis of design flow(seats/person sq.ft., tc.): Grease trap present? ❑ Ye ❑ No Industrial waste holdin aink presents ❑ No c Non-sanitary wast discharged tot e Titl system? ❑ Y s ❑ No Water meter r dings, if available: 15ins•09/08 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form ;. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M � 3T ar ra r-- Property Address Owner :Owner's Name —information is / required for --T/q c�yr every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: ate Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system 7-&'-1 tc ❑ Single cesspool /r- /rou G r' -S'-�'..� 'r r ❑ Overflow cesspool T!%✓rc des ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative 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 ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•08!08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts u Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for /�/y/ r� � +f/ 1(` �j f (l?!✓U f every page. CilylTown State Zip Code Date of Inspection D. System Information (cant.) Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Er Depth below grade: __ _ /Q feet Mater al of construction: cast Iron 40 P ❑ VC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 7/174A.-J, r .v � �v�k ray 4:;-�J("V��• �.t�-� �� f Septic Tank (locate on site plan): / C ff p C Depth below grade: V feet Material of construction: concrete ❑metal ❑fiberglass ❑ polyethylene El other(explain) L't?4,t l.0 C-e- 9,44T JX_,o'Ttt Tani If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes �o Dimensions: 41_.e.4 yTh /O e d Gil�T" Jr-;P c9h r S;P rr Sludge depth: Mns•09/08 Title 5 Official Inspection worm:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name _—information is required for every page. Utyfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(coat-) Distance from top of sludge to bottom of outlet tee or baffle 2 ) +r Scum thickness ! er Distance from top of scum to top of outlet tee or baffle 6 �r Distance from bottom of scum to bottom of outlet tee or baffle A6 How were dimensions determined? .j �� '�J�' L� S"e�'t�ty 5"riLt< !.-"r-4 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I/'(' y &r v 4 L'e 4-Z Gtr eZ fl -f` .✓ (V U �t cq ze 6 1.91-t kc e---a Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass olyethylene other(e ain): Dimensions: Scum thickness Distance fr top of scum to op of outle ee or baffle Distan from bottom of scu to om of outlet tee o affle V/ D e of last pumping: Date Uns•00!08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form a e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address C>Ldn fit r` Ave-('e-�° Owner Owner's Name information is 'Tequired for every page. City1rown State 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.): 'fight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: /float gallons Design Flow: galls per day Alarm presen Yes ❑ No Alarm le I: Alarm in working or Yes ❑ No Date f last pu pingDate C ments (c dition c.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•09108 Title 6 Of dal inspection Form:Subsurface Sewage Disposal System-Page 11017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address 4'-'04 Owner Owners Name information is i -required for ��+ ✓ �� ()tr�cf r 6lol o P every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 4 016'Z Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any Vi evidence of leakage into or out of box, etc.): f°r /'l�/i!(o,v a2 �.CI.V,✓t Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, con ' ' n of pumps app urte c etc.): ..........7 r Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: D!`Yt 14 n;;. — ."D L k-.2- rf✓ Z_z A C t 7_Z:44 CLtae 1- 751:•09108 Title 5 Offioiai Inspection Form:Subsurface sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner _ lnforltiation is Owners Name �y -required for _ �lT� /%/1/ � (�C �� �( �f��0 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): , r(gd-r __.._0're Ci�,t...� p�.......r��,tCv!'t 4 Jot! j f` Cesspools(cesspool must be pumped 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 ces ool Materials of c struction Indication f groundwater inflow Yes ❑ No t5tns-04!08 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17= Property Address -Owner -Ownef s Name information is required for eve ry page. C�tty/Tow�n State Zip O cp Code Date of Inspection D. System Information (coat.) 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, sl of hydraulic failur evel of ponding, c dition of ve etation, etc.): t5ins•09108 Title 5 OfnclW Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address riE Qs'f�Cct tyir.tJ Owner Owner's Name information is V r { `��/ —required for ��T �.y� '� _. �. l�i� (� / every page, ltyTrown Stale 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: ❑ nd-sketch in the area below Ler drawing attached separately t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address !.%vim �✓Y`Cam- ��-Lr e 1 Owner Owner s Name information is -required for TEtj every page, City/Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: heck Slope o r .rP�T E,itt Surface water /"(�vt � � Y heck cellar ,4 G If Shallow wells lt_V_A� Estimated depth to Nigh 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. Mrs•09108 Tllle 5 Offdal Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 . . ' . GILBERT REA 44 Ram SL SHEET NO, OF NO. ANDOVER, MA 01845 CALCULATED 602^9864 -----------_—___� o^rs nms�_—______--_—_- xuxLa .............i.......... ............ ............. ........... ........... ..... ... ....... ............ .......... .......... ......... ............ ..... ............ ........... .......... ....................... ...................... ............ ........... ......... .............. ............... ........................ ............. ............ .................................... ....... .......... ........... .. ........ ' Commonwealth of Massachusetts a v Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments fit`-.w r Property Address Owner Owner's Name information is ff f .-required for �_ L5 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary;A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed 'Systern Information—Estimated depth to high groundwater ketch of Sewage Disposal System either drawn on page 95 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 , �.airy t.�}fir}�.''f ::i•J3`�'S"'}� ��,hS•'Gpp}N���'�?�4� �}v4•J;�;cs�.' _ t • ',.��.��,M,..S:i:•n�T,y m �O' r�w.R.�1 i,s"a l:th ii:i Q' f•Massachusetts Wn o NORTH'ANDOVER MASSACHUSETTS syster.h Pumpjn*g Record . RECEIVED Form'4 i OEP-has provided this form for use by local Boards of Health, he System Puumping Rec rd mw be submitted to the local Board of Health or other approving a C T: ANDOVER rP 0CF N H�ALTW IJti�f?.s:r:'F'• i�rd'I' A. Facility information - Wiportantc When filling out 1.' System location: forms the - F computer,use CA...�- only the tab ke to move your cursor-do not r Clt (Town _.�,.,._ �,-.-„ T use the return y State "� Zip Code key. 2. System owner: r ' Name "."""_"""_--- _... .�..� �____...M._......,......_.__”..._�_"._._�_........._._.__---- . _...•. Addrese(lfdifferent from lacation�_ State Zip a Telephone Number - B, Pumping Record -` _. 1, Date of Pumping • p � • ©ate LOL 2. Quan#i#y Pumped: .�.__.._._.._........ Gallons Type of system: Q Gesspool(s) aSe ptic Tank ❑ Tight Tank C1 Qtber(describe): 4. Effluent Tee Filter present? Q Yes No if yes, was it cleaned? ❑ Yes ❑ No r 6. Condition of System: 6. Sy 'em Pumped By: ama .3__ Vehlc —c nw Num b Company 7.' l'ocatlon where contents were disposed., j Sl afore of Haul •4 `-"`—` .__.._." _ ._..... -- Date :�W httP://www.mask,gov/d,ep/water/ proyalsA6forms.htm#inspect l5form4,(lm,06103 System Pumping Record page [ of