HomeMy WebLinkAboutMiscellaneous - 2303 TURNPIKE STREET 4/30/2018 (2)I.
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
1) AIF:
�1 STEM OWNER & ADDRESS
J
�o. G2�2e�ol�iv
SYSTEM LOCATION
(example: left front of house)
ac�
D ATE OF PUMPING: QUANTITY PUMPEDS00CALLO",.)
Cl .:S.S 1 0 0 L: NO jj;?!!!':"'Y�ES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE i / EMERGENCY
()H,SERV.-,\TIONS:
GOOD CONDITION
HEAVY CREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
>l �'I EM PUMPED BY:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
Oj�HER (EXPLAIN)
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C U 11 'vl E N T S: L. i rl% l /✓� )6XCj -- 7"C) LeF-7P a --F 4,e/
� UNTI.'..NTS TIZANSFETZIZED TO:
05/11/2000 15:57 5083736611 STEWART/ANDOVER PAGE 02
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91VART I S SEPTIC TAMC SERVICE
47 RAILROAD grREer
BRADFORD, 1A 01835
978-372-7471
IlLY REPORT MR TOWN OF
DATE
ADDRESS
GALLONS
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Commonwealth of Massachusetts
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f l .,,own of NORTH ANDOVER MASSArtTS
- System Pumping Record
Form 4 AUG 0 4 2006
TOWN OF NORTHANDO\IER
DEP has provided this form for use by local Boards of Health. Th 8 Sfripj.irtR{�mg-FReco mu;
be submitted to the local Board of Health or other approving authority.
A. Facility Information -
Important:
When filling out 1. System Location:
forms the
computer, use
only the tab key Address
to move your
cursor - do not --/— --- -- — ------ — .---
use the return City/Town State ---Zip Code"-- `-
key.
2. System Owner:
m
Name yyy�
---
Address (if different from location) -- - - -
City/Town ----- - .. -- ------ State-------- --- -- Zip Code `--- -
Telephone Number
B. Pumping Record - --
Date of Pumping
Dat e 2. Quantity Pumped:
Gallons
Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes No
5. Condition of System:
6. Sy em Pumped By:
me Vehicle License Number
CSt Q .tq�/�YJ7q,
Company _
7. Location where contents were disposed:
_—.-
Si ature of Hau —._ _—_.._..__-
Datehttp://www.miskgov,/dep/water/ provals/t5forms.htm#inspect
t5form4.doc- 06/03
System Pumping Record • Page 1 of