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HomeMy WebLinkAboutMiscellaneous - 1001 JOHNSON STREET 4/30/2018qL V0 O 2 d N to O ocjo z cn O O X o m m o m 6' rt Imporbntz Who fiNng out fomha on the MMAK, use Q* aw ab key to move your cursor • do not use the rehhm key. Form 4 DEP has provided this form for use by local Bgards of Healt#t<.Other ( y used, but the intormatlah must be subsmntlalty the same as that p�oYidtid • a�"this form, ChWA with your local hoard of Hub to determine the form they use. The syph Pumpbtg Record must be submitted to the local Board of PWAI t or other approving authority within !4 �m tha pu date in accordance with 310 CMR 15.351, A. Facility Information 1. System locat±on: -- /06/ AOhJASO n s AddrYse l vo . A n 54 ve-e � WON 2. System Owner: 1 City/Towrh � .zip a07 Code Telephone pumbn . B. Pumping Record 1. Date of Pumpingt�bj 2 Quantity Pumped: /� Gallons 3. Type of system: ❑ Cesspooi(s Septic T ❑ TOO Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Teo. Fdter present? ❑ Yeses No Ifyam, was its? ❑Yes ❑ No 5. Condition of System: 6. System Pumped By: tN11q r Y V� =otSaC z k__s y 7. !.00811011 when contents were disposed: sipnaahne a Havle< �, Sonat" of ROMMp Faa'ft t 151on14.doa 03106 system Pwnping Record • Page 1 of i Important: When filling out fors on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts C ity/Town of System Pumping Record Form 4 i, , 2ni DEP has provided this form for use by local Boards of Health;..Other fo s may be used, but the information must be substantially the same as that provided here. BefoLths form; check -with your local Board of Health to determine the form they use. The Systg�rt Pum ing•Recormu�t be submitted to the local Board of Health or other approving authority within 14'days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: Address zy Cityrrown State Zip Code 2. System Owner: Address (if different from location) Cityrrown state ' Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 7-,F- 1 3 2. Quantity Pumped: Gallon/006 3. Type of system: ❑ Cesspool(s) eptic Tank ' ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name 130 QAC Z Q k S eQ+1,C_ Company 7. Location where contents were disposed: �s b e -eq Signature of Hauler Signature of Receiving Facility t5for4.doc• 03106 Vehicle License Number Date Date System Pumping Record • Page 1 of 1 FOWX 4 - SYSTEM FUMYNG IECORr. Commonwealth of MassachuseUs J) 8 1DOO'Q--'N , Massachusetts �Estenr .humping .Record �rstr wner SS ysiem Location Ob M Lj?� W4 Type Emergency ❑ Routine fK Crssp( )I. No ❑ Yes ❑ Stptic 1-31iR: No ❑ Yrs Dater ' Pumping- ? Quantiry Pumped: O _ gal'ons S. sten Pumped by (Company): Bo RACZ'EK'S Permit - Conic is transfe-reo to: RECEIVED HEALTH DEPARTMENT Cent. )is disposed a(: K Da Pumper Sienature Conc ;tion of system)oukr comments: 1 { 1 v OEY nJFROV-M MkSl - 1:)0)M FORM q . SYSTE`M PUM1 NG RECORD Commonwealth of Massachuselts A,1 Massachusells s Stena.hum in ,Record ,ystem oca%ioJn /"c CX i ,� ��•� y.� .RECEIVE® '. JUL - 6 2004 TOWN NORTH N [P HEALTH DEPARA�N' Emergency ❑ Routine �..�� Yes ❑ S,-ptic Tank: No ❑ Yes Cesspc �I: No ❑ ocl!ons Quantiry Pumped; Pumping: �_._-- ._,.. BO RACZEK'S Permi� S\ s[e! Pumped by (Company): Come .is �ra�sfeRed to: r, ni. ,Ls disposed ae: —Qr e pumper Sitnaru Conc i(ion of system. ocher comments. DEQ AYPROY-CD FOR I I:/o 7191 JYSIe :1 wne--. r -- P25& /00) FORM 4 - SYSTEM PUNTNG`RECORD Commonwealth of Massachusetts �ND-5)v , Massachusetts _S_ystenz FPUM rn Record ystem ocatton /, PD©uc�\ nCVS-( C r — 9 2002 Type Emergency D Routine D� Cessp( DI: No ❑ Yes ❑ Septic Tans:: No ED Yes Date c :• Pumping: ~C), Quantity Pumped: / �D� _ gallons (�� 5t : S\stela. Pumped by (Companep`-, P Per -mi � v): ! l��L�C° Z ���---, Contc is transferred to: Cont. Its disposed at: p`�c 1'-�- Pumper Sienature— �eI Con( (tion of syslerrvother comments: 4 k--,) DEP APPROVED FORM • 12/0795 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL QUALITY ENGINEERING 0 NOTICE OF RESPONSIBILITY PURSUANT TO M.G.L. CHAPTER 21E cis p j&&� ,A W�L On ( at 914u1 ' -' 45 p. /irf"-.+ the Department of Environmental 'R:.o J e�0 (, (Department) resl?o ndeql to a rele se/threat—of release of oil/hazardous material at ,(µk@, ���j• ,, �� l'/o:t,i�iyv► tL y=:� � [ra51� 1 in • o✓ , Massachusetts (the site). �CW� Preliminary indications are that pursuant to section 5 of M.G. L. Chapter 21 E re a party responsible for assessment, containment and removal actions necessitate by this incident. Massachusetts General Laws, Chapter 21 E, places liability on responsible parties to: (1) pay for all response action costs associated with the incident and (2) compensate for any damage to natural resources resulting from the incident. You may assume responsibility for emergency response actions/costs by paying for all response costs incurred by the Department relative to this incident and immediately performing the items checked off below: Hire a spill cleanup contractor acceptable to the Department to take all necessary emergency response actions (i.e. assessment, containment and/or removal) as required by the Department. [M Dispose of the contaminated soil generated at the site in conformance with the Department's current policies for management of virgin petroleum -contaminated soils. Written approval must be obtained from the Department prior to removal of the soil. Collect soil/water samples before and after cleanup, from the impacted environmental media and submit results of a certified laboratory analysis for: 10 Submit a report providing an accurate description of the incident, response actions taken relative thereto, and site conditions (including supporting documents) immediately or upon receipt of analytical results. 10 Other, � 7'� The above actions must be performed immediately and19(completed no later than -9 Depending on the information/data generated by the above work, the Department may `rquire additional remedial response actions. If you fail to complete the response action(s) required by the Department within the required timeframe, the Department will take appropriate response actions and seek to recover all costs, charges and damages. By accepting responsibility for conducting the required response actions now you can: -minimize administrative costs incurred by the Department in handling this matter (in spill cases, administrative costs Incurred by the Department are at least $1,000.00); - avoid interest charges on the total liability at the statutory rate of 12% compounded annually; and - avoid treble damages (i.e., 3 times the total amount of response costs the Department incurs). This liability constitutes a debt to the Commonwealth. The debt, together with interest, creates a lien on all your property in the Commonwealth. In addition to the foreclosure remedy provided by the lien, the Attorney General of the Commonwealth may recover that debt or any part of it in an action against you. You may also be liable under M.G.L. C. 21 E, section 11 for up to $100,000 in fines or penalties for each violation of C. 21 E as well as for additional penalties or damages pursuant to other statutes or common law. The Department encourages potentially responsible parties to provide or arrange for response actions to minimize the Department's response action costs for which you may be liable. The Department's objective is to ensure public health and safety and to protect the environment. Only with your help can this goal be achieved. Please submit the rlquested inform ion and direct any questions regarding }qis matter to A JS at the ,� - V � L'�� -`� Regional Off ice. /0 Cmivn e4� _ b��K' Massachusetts, telephone #(Z)g3s _2J6 Very truly oursADEQ Name an Titlficial z q� On � 3 at approximately + �cIp of the above BELE Office served upon personally._ by certified mail a copy. of the above "Notice of Responsibility". Person on -scene agrees does not agree to take the response actions deemed necessary by the Department. Copy Distribution: White/Potential Responsible Party Yellow/Boston Pink/Region Golden Rod/RegionI > 1d iq r -- �—' ``�` �• •— (fD • �ila:, -tF 1- 21 �%/�l7 J�e, df(���C �� � c-y� �s • �UD� JDlansayj �•� /V, , CREIRTIFICATE OF USIE a OCCUpA13Cy - 41" -Buildifig Permitumb'� 2Z7 N Date - April :?I 1976 THIS CERTIFIES THAT THE BUILDING LOCATED ATED ON Johnson Street MAY BE OCCUPIED AS a _Dwelling -& 2 -car" gara IN ACCORDANCE . Re under WITH.THE ,PROVISIONS bF'THE BUILDING BY-LAW AND SU'- CH0 THER REGULATIONS AS -. r MAY 'APPLY" , 0 CERTIFICATE ISSUED TO Robert Mansour SLY" ADDRESS 1 )l Johnson Street, North AndoverMass. , _ CHO Building Inspectot. I I . R A O 11 m T �N y• va � rl 0 to 3 on n 1n m O z ry+ m o0 =a �' ` v ., z -�' D v ca _0CL v V -2 _ °0 O C. O T 0'R A H A 'G l� O ry vi R A ` 11 m �N N iA to on n 1n m O z 900 m o0 r �' ` O -A t� 00 10 pmh ,6 t P-ERMIT NO. ate_ t APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP NO. ZONEI LOT NO. SUB DIV. LOT NO. 2 RECORD OF OWNERSHIP iDATE II— BOOK PAGE LOCATION PURPOSE OF BUILDING�C ��,���111 �(1,' N/44 ©' l w .A/�� OWNER'S NAME ..Qi,�. `/V, NO. OF STORIES Sa E • -,, OWNER'S ADDRESS w..C• /L t) r,a bd "BASEMENT OR SLAB ARCHITECT'S NAME //��� /�' �[/� �, E� �l� r�41 IZE OF FLOOR TIMBERS IST tL.A" JND 3RD BUILDER'S NAME �c� �/Q c3ej -Lv( 87 3 _ SPAN AC DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET '16 POSTS DISTANCE FROM LOT LINES - SIDES 7 s 'f 3s REAR /5 C 7 " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION .1� f� THICKNESS /a IS BUILDING NEWA,� Yom` SIZE OF FOOTING !/, er d3 X16 to, U IS BUILDING ADDITION MATERIAL OF CHIMNEY -- fn IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND /9~A i. I WILL BUILDING CONFORM TO REQUIREMENTS OF CODE 41— �j,/,jl IS BUILDING CONNECTED TO TOWN WATER .6Y_a,P.X J0 BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE . ,24 INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR ./ DATE FILED S4S Y LJRE OF OWNER OR AUTHORIZED AGENT FEE PERMIT GRANTED s^ 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST 5�..� EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. s C 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INSPECTOR 'NV -Id 101d S30V1d3U SIHl 'a3SOdW12d3dnS '013 's3ovzi -VV 'S3H:)80d H11M 'SJNId11n9 d0 SNOISN3WIa 10VX3 4NV S3N11 10"1 W02Ld 30NV1S1❑ aNV 101 JOSNOISN3Wla lOVX3 MOHS1SnW N01103S SIH1 z I AONVdn00o L (380:)311 ONiciins 0NIIV3H ON I +'i JIaIJ313 110 -IPi£ P"L 1.W.9 SWOON 40 'ON L SV0 Sa31V3H 1INn 0.I.H 1NVIOVa ONINOI114NOJ dlV aOdVA 210 a.l.MlOH WM31S Nand aIV IOH 03J210d 3JVNand SS313d1d _ _ SnAyd QOOM S10J I 'SW9 1331s SlOD T Sw9 a39W11 1SIOf BOOM 9NI1V3H L L II `JNIWVad 9 Oa VO 3111 aOOld 3111 S36nlXld Na300W JNIdOON 11M _ 83MOHS 11V1S 13AVdO B aVl _ ON19Wnld ON 31M1s NNIS N3HJ11N S30NIHS DOOM AaO1VAV1 S310NIHS 1IVHdSV 13SO1J a31VM 03HS 4a VSNVW F7113a9WV�J 1Vld ('X13 Z) MM 131101 'Xld s) H1V9 dlH 319VO ONI9Wflld OL dOOa3NON 5 3aOld3das —F—,0 -0d H WHIM _I a001d 8 'Sdis JI11V 3WVad NO 3NO1S UNOSVW NO 3NO1S 'N19 a34NIJ a0 'JNOJ 3WVad NO NJIH AdNOSVW NO NJIa9 —� E l 9 3111 'HdSV 3WV NO OJJnls A2INOSVW NO OJJn1S ONIOIS 'la3A NOWWOJ — ONI41S SO1S39SV t],MGd VH ONMIS 11VHd SV HAV3 S310NIHS BOOM 313aJNOJ1 aa SGdV09dV SHOOId 6 �I S11VM b N3HJ11N N8300W WOO8 OV3H 1.W.9 ON %i 1/1 /1 llnd M3aV S3JVId 3ald V3aV JI11V *NH V3aV .1.W.9 'Nld 1N3W3SV9 E — E Z I 9 NIdNn 11VM Aa0 a31SVld Sa3ld O.MOaVH 3NO1S a0 NJla9 3NId 'N.19 3138DNOD 313aJNO5 HSINld 80133INI 8 N011VONnod Z N0u:)nN-LSN00 S1N3W1aVdV S3J1ddO AIIWMd '111nW S31a0!S I I AIIWVd 3101\1IS z I AONVdn00o L (380:)311 ONiciins H H W CA O 00 t/� _ � W cc LLI V O W Q ya O Z-5 J k (4 Q I t7 N V Z > Q � WO I z d Q Q th = 0 p��� J 0. d ~2 �I N H � lute~ H 2 ti V 4CL H W �% S m CD V �l N J O W I. Z-5 J OP LU W d ~2 H � V 4CL � S I p so 0� C z _ Lo ,�Z m W I% r .. ui � m N J Z o J .. O H W d Q OC 1 cis ® s z W r ~cj! M L H H d O W W H O J y z N IW- a N C Q N D t/) W V RAY G. MANS-OUR..,[N,C i '•' ENGINEERS AND- CONTRACTORS 3 ! PROJECT.-- -------- --------------------------_ ----------------------------------- FILE NO .: ---' -------- s - — r l 8 SUBJECT --------------------------------------------------------------�—=------------- SHEET NO..:_ �------ F:: ___ �^• COMPUTED BY___f o �L'•------------------CHECKED BY---�� `4�------ `------- DATE _ y� 1L _ � _ 1 5 1T s. ►"� VVV " R,�Y N R sl S e � 1 I. MR MR RAYMOND G. MANS -OUR INC. ENGINEERS AND CONTRACTORS -------------- SUBJECT -- € "�-��:--?- �-P i$ -� - -� -.r isme------------ T------------------------ COMPUTED BY___1_7,_I.�-L-L------------------ CHECKED BY.----------------------------• FILE NO SHEET NO. 7 ___OF DATE b� r '. 7 17 115 T� Cl FILE NO SHEET NO. 7 ___OF DATE 17 115 T� FILE NO SHEET NO. 7 ___OF DATE RAYMOND G. MANs,, UR"INC',: - s ?. ENGINEERS .AND CONTRACTORS' '* PROJECT.------------------- ------------------------------------------- ---------------- FILE NO.------- -- - =- OF.--- • SUBJECT ----------------------------------------------- ----------------=---- ---- SHEET NQ. -__z---- COMPUTED BY ---------------------------- CHECKED BY.--------------------------- - . DATE jV ' RAY11 0NO G KAR f4:SQUR INC. ; f , ENGINEERS AND 'CONTRACTORS r�`'• ` PROJECT.-----------------------------------------------------------------------=-- FILE NO __�----------------- -----------SUBJECT--------------------------------------------------- SUBJECT -------------------------------------------------------- SHEET NO._r_,OF.__-_� , a. COMPUTED BY----------------------------CHECKED BY------------- --------�----.----• DATE �cJl;1LZ _ t 9�7 ✓ ;: •• pe5tla�1 nnrA. � +•• ' t ,A. 'u QAXI 0Q T► NSE +' Zvi %K.J 9 ILA a i t FL0\A/ = 40• Beo Zoo *5 k Z� Viiia Flom! - 3 x 2x t"O - 3c.0 <40, Ft,avV = 300 -F- Zs . C300 f % . �f�Qt p.��. �"4f�.��;10 C?. -!")S G-7 P t7 ; yrs I ��..++yy��A / 6t 412GUO .S Q. rCC In. �,//') t..,, �•�'� /,+/� A ++/�� }may\ i -. r1 � f w "^+.spa+�+�o�riw+�r.e.oe�...�rrwow.a.r_.-'.a�"sr'°"rr�r�9r�+r rYerr'•1 4,. Y '.f. FtA'YMOND'i MA•NS`OUR CNC.: t` k► t ENGINEERS' AND CONTRACTORS `. PROJECT---------------------------------------------------- --- --- ---------- c--- - -- FILE SUBJECT---------------- __--- - SHEET NO COMPUTED BY----------------------- __---CHECKED BY._____-------�---__-• t DATE------ C-)�'a� E \ �� •�t <r 'AIN) r � f 7, cool IL Od-I j u 0 ill LI, t l ' . , f '1• ^ 'i ` �t - 4, !.7!ti. F ., t 4 [�• '7 2'i. �..,7 rn., V I .y J.. .3 4 .. .... .. r —. J -y.t �•'^"......_c.-.. l t't RAYMOND ''G NI=ANS.OUWANC • s k a 4 ENGINEERS AND CONTRACTORS _--_ PROJECT. ------------------------------------------------------ s =------------ +' SUBJECT ------------------------------------- ---------------------- -------------------- SHEET 1-�0._ r. ,. 1. COMPUTED BY ----------------------------CHECKED BY -------------- -------- ------ k ---- • DATE��.G..L_ �'JS__-_ ;RAYMOND G., r.CONTIR MORS ENGINEERS AND. �C PROJECT------------------------------------------------------------- --------------- FILE NO. --i-- SUBJECT---------------------------------------------------------------SHEET N------------- 0. 7 ----- OF.- COMPUTED BY ----------------------------CHECKED BY.---------------------------- DATE LEA,6i4itAL-i Prr Pt. A_ Ayo.:-se4-rioAJ J . 4 rl\ � I CERTIFY THAT THIS LOT 13 NOT IN THE F.I.A. FLOOD HAZARD ZONE. THIS CERTIFICATION IS DASED ON THE SURVEY MARKERS OF OTHERS. AND IS ,NOT A PROPERTY SURVEY, FOR MORTGAGE PURPOSES ONLY. I CERTIFY THAT THE BUILDINGS ARE LOCATED AS SHOWN, AND THAT THEY CONFORMED TO THE ZONING/ BY-LAWS OF THE ff—V'f/TOWN OF �a,- vHEN CONSTRUCTED. SCALE I-- DEED "DEED BOOK AREA PLAN ASSESSOR MAP BLOCK LOT PAGE k �v I — OF Rt�BSERT yJ, P. MQRRIS H N0. 221510 -0, CE CERTIFIED PLOT PLAN OF LAND iN AS DRAWN FOR 1, flel- 7" R.A.M. ENGINEERING 160 MAIN STREET HAVERHILL, MA. 508-372-0449 FORM 4 - SYSTEM PUMPING RECORD OF Commonwealth of Massachusetts y�R°,Oy IV°HV,- �1-4,vpduzj�, , MassachusettsL0v 6 System Pumping Record -.� ' 5y em uvrner System ocation db�..1v +t„ R /00/ "��nNS©a,' r� � Type: Emergency ❑ Cesspool: No ❑ Yes ❑ Date of Pumping: Routine OZ SLptic Tank: No ❑ Yes Quantity Pumped: / _ gallons Svstem Pumped by (Company): (pf�C`�Z Se�`f �C Permit -: Contents transferred to: Contents disposed at: A16vlefl� , � Date Pumper Signature Condition of system other comments: C.yoo n iiDFP APPROVED FOR.',t - 12/07/95 - �, Commonwealth of Massachusetts C yffown of NORTH ANDOVER. MASSACHUSETTS System Pumping Record Foirtni 4 DEP has provided this form for use byfocat Snrde of lfealth. The System Pumping Record must be =bmfftd-toVwiocal Board-aMeaith tar oflw approving authority. A. Fac.114 Information (—'R d-iVED lilf -=A forms on the QWvU er. use only ffm tab'key *mae vur" - 04 nod Las the return W. 9.. Sy�m.I.ocatiara;. /©O ac��tksa,- %/ vav e r 2. -Symm Owns: OCT 12 2007 40WF N OF NORTH ANDOVER EALTH DEPARTMENT state Zip Code Address Cif different from bcabon) Cfty/Town 5'taba Zip Code Telephone Number b ' iiat a ►t=om s, (sl 1. Cate of urnping nets 2. Quantfty Purnped; -z coo QQRM 3. -Type of system: Cesspool(s) `Q� Septic Tank El Tight Tank Q Other (descfibe); T 4. Effluent Tee Filter present? ❑ Yes �(No If yes, was it Cleaned? [] Yes [2 No 5. Condition of System: $. Syste , Pumped By: Name Veftkft License Irfunrber 7. Location where contents w9re. o ,Lo, .srfow"t httpAW w.mass. ht Ti inspect -7—/�_07 Date - 51bfMA.doo. O&M Roeorti • Pada i of t weer /661 L..-' IF3- IsteM ; Location r I T` -pe- Emergency: ❑ Routine D� Y ❑ S� tic Tank: No 11 Cesspc ��I: No ❑ Yes p : 2G- Q—uaiPumped: 6UO Date (` PumpinG _gallons -- — .8�,7►RACZEWS Permit S�•ster; Pumped by (Company): Conte .ts transferred to: Cont:.)ts disposed at: /Gt Y7!r el Date 4 -Pe -"/?r Pumper Signattr►Co•,,,_�`���% Condition of system other comment$: -DEP APPROVED FOR.%t • 1:/07195 , Commonwealth of Massachusetts City/Town of Merrimac RECEIV�� System Pumping Record Form 4 ANDOVER DEP has provided this form for use by local Boards of Healt .-Wer yris , but the information must be substantially the same as.that provided erIs form, check with your local Board of Health to determine the form they use. The Sys em Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1. System Location: on the computer, ) use only the tab %Qll�— key to move your Address cursor- o not usethe reeturn _ 449- A,,/o Ile- 6— MA 01860 . key. City/Town State Zip Code VQ 2. System Owner: Name gun Address (if different from location) City/Town State Zip Code -76d�3 - 7e yy Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: /000Gauons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number BORACZEK'S SEPTIC & DRAIN Company 7. Location where contents were disposed: Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record Page 1 of 1