HomeMy WebLinkAboutMiscellaneous - 574 SALEM STREET 4/30/2018 574 SALEM STREET
210/038.0-0101-0000.0
Commonwealth.of Massachusetts
City/Town of i
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health.. The System Pumping Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When fining out 1. System Location:
forms the
computer,use
only the tab key Address
to move your hT ] - 1 y ROS
cursor-do not
use the return Cityrrown tate Code
key. 2 System Owner
Name
iRTW ANDOVER
Address(if different from location) O
WCwALfti
Cityrrown. State ,
Zip Coder
Telep one Number
B. Pumpi.I' Record
J. Date.of Pumping Date 2. Quantity'Pumped:
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. Condition of System:
6. System Pum ped B
Name Vehicle License Number
Compan -- .
7. Locati whe a conte vy isposed:
f�
Si a'tur o Hauler Date
http://www.mass.gov/dep/water/approvalt/`t5forms.htm#inspect
t5form4.doc•06103 System Bumping Record•Page 1 of 1
Commonwealth of Massachusetts
A40y-la(Massachusetts
System Pumping Record
System Owner System Location
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j Date of Pumping: �r6(9 Quantity Pumped: �06L)gallons
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Cesspool: No Yes L_l Septic Tank: No Yes
System Pumped by: LSarcoort git&7rf taa License#
Contents transferrred to : Greater Lawrence Sanitary District
Date: __ Inspector
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TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
6
��QrC�o✓`
cs � S � S
DATE OF PUMPING: O'1T� QUANTITY PUMPED : 0 OC7 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: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: S `
Vii' 2 5 2001
TOWN OF NORTH ANDOVER ,
SYSTEM PUMPING RECORD ._.
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
64 . l �c k OT- kbu5e
DATE OF PUMPING: (0 -o QUANTITY PUMPED ooCD.- GALLONS
CESSPOOL: NO YYES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE JEMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: `� :