HomeMy WebLinkAboutMiscellaneous - 1592 SALEM STREET 4/30/2018 (2) 1592 SALEM STREET
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210/106.B-0057-0000.0
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Commonwealth of Massa huQ14
City/Town of � -
TOWN OF NORTH ANDOVER CI V r—U _
System Pumping Record- HEALTH DEPARTMENT
Form 4
DEP has provided this form for use,by local Boards of Health. Other forms aybe'used, but the .AVER
information must be substantially the same as that provided here. Before us ng.this form,check,'�fA wi�th y .ur
local Board of Health to determine the form they use.The System Pumping ecoid must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System LocationaQ Right�nt of holase;Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address �• ��� � �C/���
CitylTown State Zip Code
2. System Owner.
Name
Address Cd different from location)
Citylrown Stat — �Z>,,�Code
Telephone Number
B. Pumping Record
1. Date of Pumping �2. Quantity Pumped:Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No.
5. Con. ditinofSystern:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locati ere contents were disposed:
C� S. Lowell Waste Water
SignAtufe 9t HaullerU Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
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FORM - SYSTEM PL-NH-TNG RECORD
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Uwner System Location
Date of Pumping -� Quantity Pumped:
Cesspool: No It Nkf ties ❑ CPntir Tanl•• XTr% Yes
System Pumped b%-- License #:
Contents transferred to: - 1
Date Inspector
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
KVA� (example: left front of house)
5 9 C2,- 6a 6K A
DATE OF PUMPING: i c2-17-01 QUANTITY PUMPED 1 0c C-1 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE 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: g: Y Scy/
OWNBOASID 0�AOR Y
COMMENTS:
DEC 21 2001
CONTENTS TRANSFERRED TO: