HomeMy WebLinkAboutSeptic Pumping Slip - 127 TUCKER FARM ROAD 8/30/2017 EIVED
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,SYSTEM OWNER & A[DRESS
SYSTEM LOCATION
DATF OF PUMPIN( : w�� «.. ..__..__._._._..
.. . .._QUAN'["ITY PI)MPI:[>.. ..
C I;SS DOL: NO YE:S
._..... SOPtic Cwlk: NO, YES
N"a FL)I<L OF SERVICE: KOIJ'['INI'. HMl,"R(,IEiN(.')'
SE'RVA['IONS:
GOOD CONDITION FULL TC) COVER
HEAVY CREASE BAFFLES IN PLACE.
ROOTS _....__ LEACH.>i' MLD RIJNBAC K
EXCESSM SOLIDSFLOODED
-SOLID CARR
YOVER..._..._-O 1 HER EXPLAIN
`)Ystefrl Pumped by
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Zee_m
UN MN"I'S I`R,ANS4'LXR,ED 10
i
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS ",,\
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of He Record must
be submitted to the local board of Health or other approvrno a41l*xr*4'VED
A. Facility information AJL 0 7 2008
Important:
When filling out 1. System Lodation: TOW1 U� `IO R I H Al'�DOVE
DF 1/,J C1 ME"e\H
forms on the
computer,use
only the tab key Address
to move your Aj I Or
cursor-do not City/Town State Zip Code
use the return
key, 2. System Owner:
V
0100
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3, Type of system: El Cesspool(s) [N-M' Septic Tank El Tight Tank
F-1 Other(describe):
4. Effluent Tee Filter present? E] Yes El No If yes, was it cleaned? El Yes F1 No
5. Condition of System:
a_N 17-1
10
6. Stem Pumped By:
0- 'a a f"�(, I-0(D111i-k-1L -- --.(
e Vehicle License Number
Company 1
7. LocationyMere contents were disposed:
-Signaae of Hauler Date
http://www,mass,gov/dep/water/approvals/t5forms,htm#inspect
t5form4.doc-06/03 System Pumping Record -Page 1 of 1