HomeMy WebLinkAboutMiscellaneous - 83 ACADEMY ROAD 4/30/2018 (2)4--
O
T
z
Fl
0
--
'
IIa
f�
U
d
0
O
C
O
a
L
'
a
L
l
�
a+
p C �
Z
L.
C
�
mCX
a
CD
L
AC V
�L
L
r1
C
N
G E =
�
S
Co
U C
R
O
Z
c
z
a
c
U
v
F-
c
�
O
C
Q
C
Q
cc
U
O
0
C .
U.
0
S
CURRIER
SEPTIC & DRAIN SERVICE
107 FORES'[SlUEFT; MIDDLETON, NIA 01949
(979)71 74-2772
, I —
MvW0XlX"EALTl I OF MASS,ICHUSETTS --
ANdoU'r-J.- _'MASSACHUSETTS
S17STEM PUMPING RECORD
SYS'AMM OWNER,
k C-fty S+-- V le V
cl � )4 f) 4- t -y
N .. � u o(o V'Q V
SYSTEM, LOCATION:
ES e t iv d `,goy
GOd2v-f to
DATE OF PUIMPING. 0- '(0
-9-060
QUANTI'lY PUfvlPFD:—,Z-Q ()
GALLONS
CESSPOOL: NO YES
S -F PTIC TANK: NO 7-1 Y -s
';Yq
STENA PUTIMPED BY: CURRMR SEPTIC & DKAJN SERVICF,
CONTENTS TRAI\TSFERRFD TO6:- L
Ab --INSPECTOR:
-1k, ,,FORM 4 - SYSTEM PUMPING RECORD
CURRIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978) 774-2772
'COMMONWEALTH OF MASSACHUSETTS
4 y? d QV P✓` , MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNER:
Ic, L/ eG--\ S \
e3 ,/44 �do/V
�
DATE OF PUMPING:
CESSPOOL: NO 0 YES
SYSTEM LOCATIO 1
� C I� 6 • vI o �-c s � \(\,A
Q
QUANTITY PUMPED: - 4 GALLONS
SEPTIC TANK: NO ED --"YES F7
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE: ` L11)1 INSPECTOR: o
1
�•r,:�CF
10
SEPTIC JjPAAN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978)774-2772
COMMO ALTH OF MASSACHUSETT:
O f le MASSACHv
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
\\\j
System -Pumping Record
lY Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
ietwn
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
1. System Location:
2.
JAN 1 0 2008
Addreess) n ___j i vv, , ,' j)" � � .
ni4w
`�. A r, �vv e r Mn HEALTH DEP�rsL
City/Town State I Zip Code
* e.V
Name
Address (if different from location)
City/Town
B. Pumping Record
Stale Zip Code
Telephone Number
1. Date of Pumping //—/6-03 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) 591.. Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes'®: No
5. Condition of System:
C), 4-
6. System Pumped By:
eke wy`rs��
Name
Company
7. Location where contents were,disposed:
If yes, was it cleaned? ❑ Yes ❑ No
v-Sa r)1 �9 _
Vehicle License Number
__ _
Signature of Hauler VDate
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
WRI
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1