HomeMy WebLinkAboutMiscellaneous - 14 Christian Way i
� �-
� ;
,�
��
� �
.�
. �
E
� ;
� .
-% � �
/j(.Q �r
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: `1- L-0
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
tAl Owl, �ot� o�
DATE OF PUMPING: `(— l-0 QUANTITY PUMPED ��y 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: �20 VS
COMMENTS:
CONTENTS TRANSFERRED TO: L'
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Type: Emergenc Routine
Cesspool: No Yes Septic Tank: No Yes
Date of Pumping: 0 G Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
of A
O.Y
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
Dep Approved Form-12/07/95
"-11�
-7,0
PV/
V
�Oh
TOWN OF NORTH ANDO �o
SYSTEM PUMPING
� v
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING:9--A -v�QUANTITY PUMPED �SS"GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE L� 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:
�. - -
COMMENTS:
CONTENTS TRANSFERRED TO: �"
J�- Commonwealth of Massachusetts
City/Town of vAN 17 2013
system Pumping Record NORTH ANDOVER V
Form 4 -�
y DEP has provided this form fqr use by local Boards of Health. Other forms may be used,but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:
When filling out 1. System Location:
forms on the
computer,use �
only the tab key Address
to move your
- Zip Code
cursor.do not City(Tow/�(J/�n" - r — State
use the return
key. 2 System Owner:
Name
� Address(if different frorm location)
- — Zip Code
CilyJTown State
_`? - gG -- 3eVY
Telephone Number
B. Pumping Record
�y^ /Z=- r
1. Date of Pumping ate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic.Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L-T rvv If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sys
6. System Pump B
- -
-- --
---- — .- —
-— Vehicle License Number
Nam
N G.L.&D.
Company �.,�L
7. Location where contents were disposed:
An&�� r
?nalu�re�
1 Date
— _- - Dateeceiving Facility
System Pumping Record•Page t of 1
15form4.doc•03106 A