HomeMy WebLinkAbout- Title V Inspection Report - 160 CARLTON LANE 4/29/2019 lei �CEIVED
Commonwealth of Massachusetts
City/T own of' NORTH ANDOVER
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System Pumpling Record
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DEP has provided this forte for use by local Boards ofHealth. Other forms may be used,, but the
information must be substantially tha seas,as that pirlovided here. Before using this form, check with your
local Board of Health to,determ,ine the form they use. The System, Pumpli ig Record must be submitted"t
the local +yard of Health or other,approving authority within 14 days from the pumpinig date i f
accoridan ce with 310 C M R 15.35 1.
A. FacmIty inTormatilon
Important when
filling out forms 1. System Loc tilon
,the computer,
use nl tl�u CAR H ROAD
.... .......
key t rove your r �
cursor-do not
ICI '
City/Townuse the return State Zip Code
key.,
tab 2, SystemOwner,:
DARRE,Nl'WIN I
mm
Name
Address(if different from location)
City/Town State Zip Code
B. Purnping Record',
M Date 'cur inDate , Quantity Lumped., .m
`l _rvr
ons
3. Component* C s 1 s Septic Tank F-1 Tight Tank Grease'trap
EJ Other(describe):
. Effluent Tee Filter present? Yes El No If yes, was it cleaned? Yes 0 N
5. Observed condition of componentpumped:
FOOD
. System Pumped
JAY CURRIER H79406
Name Vehicle License Number
TS SEPTIC & DRAIN
Company
. Location where contents,were disposed:
G SD
41/9/19
Signat,u! of Ha",uler Date
-Signature of
t
o-
Receiving!Facility(or attach facility receipt) Date
t5form4ll,doco 11 2, System Plumping Record Page 1 of