HomeMy WebLinkAboutMiscellaneous - 125 SAW MILL ROAD 4/30/2018 (3) r
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: �Qo�
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
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DATE OF PUMPING: 1`1o2QUANTITY PUMPED 1 SOe7 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE Y EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: iso450✓L rv�-
COMMENTS:
CONTENTS TRANSFERRED TO: r!y--- L` �
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INV P/PE OUT OFAVOE 1$2.00
INV PIPE INTO T4NA' /g/ 7y - SUU -SU�F,4CE D/,�f'OS,4L
INV. PIPE OUT OF TANK /g/.y9 191- 30 SYSTEM
/NV PIPE INTO D. BOX /97./7 186.5$
INV P/PE OUT OF D. BOX /p,00 1'96. 67 /N
INV END OF P/PE Pit A 186•So 186. y8 North, Andover , mass.
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Commonwealth of Massachusetts
City/Town of -LIVED
� System Pumping Record
Form 4 APR 0 9 2008
DEP has provided this form for use by local Boards of Health. Othe form may,WbWCbutthe
information must be substantially the same as that provided here. B with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. SySt2�'Tl � l `�.LOCatI
forms on the Il, 1 /1�
Q
computer,use -/
only the tab key Address �Ll� �t�/T �V
to move your
cursor- not Ciyfro �� State Zip Code
use the return
key. 2 System Owner: T� 'A I
Name
lel Address(if different from location)
Citylrown State An Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ esspool(s) �—ftic Tank ❑ Tight Tank
they(describe):
4. Effluent Tee Filter present? ❑ Yes E]-I o If yes,was it cleaned? ❑ Yes ❑ No
5. Coon of Sys +�7L,
1 bCLA—
c�
6. SysteF P �
Name �x ^ � Vehicle License Number
Company
7. Location where cotents were dis
r7l:
Sigtaturyoft
auler Date
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