8 PETER ROAD ��T�� /� s�pr�c�
��
7 D
577 MAIN STREET S� ` C 9 2W.
HUDSON,MA 01749
800499-1682 j/ OCT 6 ,. 2004
CITY OF SALEM
BOARD OF HEALTH
WTVDl?-TV-El?
ENVIRONMENTAL
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNER'S NAME: FEENEY,RAE
PROPERTY ADDRESS: 8 PETER RD., SALEM, MA 01970
ADDRESS OF OWNER: SAME
(IF DIFFERENT)
DATE OF INSPECTION: AUGUST 30, 2004
NAME OF INSPECTOR.-THOMAS CHIGAS
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 8 PETER RD.
SALEM,MA 01970
Owner's Name:FEENEY,RAE
Owner's Address:8 PETER RD.
SALEM,MA 01970
Date of Inspection:AUGUST 30,2004
Name of Inspector:(please print)THOMAS CHIGAS
Company Name: Windriver Environmental
Mailing Address: 577 Main Street
Hudson,MA 01749
Telephone Number:800-499-1682
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
YES Passes
_ Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
f
Inspector's Signature: Date: AUGUST 30,2004
The system inspector shall submit a cop of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 8 PETER RD
SALEM,MA
Owner: FEENEY
Date of Inspection: AUGUST 30,2004
Inspection Summary: CheckQ B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
YES I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303
or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
NO One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the_for the following statements. if"not determined"please
explain.
NO The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
NO Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
NO broken pipe(s)are replaced
NO obstruction is removed
NO distribution box is leveled or replaced
ND explain:
NO The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
NO broken pipe(s)are replaced
NO obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:S PETER RD
SALEM,MA
Owner: FEENEY
Date of Inspection: AUGUST 30.2004
C. Further Evaluation is Required by the Board of Health:
NO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
N/A Cesspool or privy is within 50 feet of surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
NO The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
NO The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
NO The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
NO The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance_
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:N/A
f
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: S PETER RD
SALEM,MA
Owner: FEENEY
Date of Inspection:AUGUST 30,2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
NO Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
NO Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
NO Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS
or cesspool
N/A Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
NO Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
NO Any portion of the SAS,cesspool or privy is below high ground water elevation.
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.[
NO(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to
determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes no
_ N/A the system is within 400 feet of a surface drinking water supply
_ N/A the system is within 200 feet of a tributary to a surface drinking water supply
N/A the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional ofice of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:S PETER RD
SALEM,MA
Owner: FEENEY
Date of Inspection:AUGUST 30,2004
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
YES _Pumping information was provided by the owner,occupant,or Board of Health
NO Were any of the system components pumped out in the previous two weeks?
YES _Has the system received normal flows in the previous two-week period?
NO Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
YES _Was the facility or dwelling inspected for signs of sewage back up?
YES _Was the site inspected for signs of break out?
YES _Were all system components,excluding the SAS,located on site?
YES _Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
YES _Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
YES _ Existing information.For example,a plan at the Board of Health.
_ N/A Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of
distance is unacceptable)[3 10 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 8 PETER RD
SALEM,MA
Owner: FEENEY
Date of Inspection:AUGUST 30,2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual):4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents:3
Does residence have a garbage grinder(yes or no)?NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): N/A
Seasonal use:(yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)):7300cf
Sump pump(yes or no): NO
Last date of occupancy:CURRENT
COMMERCIAL/INDUSTRIAL
Type of establishment:_
Design flow(based on 310 CMR 15.203):_gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):_
GENERAL INFORMATION
Pumping Records
Source of information:OWNER
Was system pumped as part of the inspection(yes or no)?YES
If yes,volume pumped: 1000gallons--How was quantity pumped determined?SIZE OF TANK
Reason for pumping: CHECK TANK'S INTEGRITY
TYPE OF SYSTEM
YES Septic tank,soil absorption system
NO Single cesspool
NO Overflow cesspool
IVO Privy
NO Shared system(yes or no)(if yes,attach previous inspection records, if any)
NO Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
NO Tight tank_Attach a copy of the DEP approval
N/A Other(describe):
Approximate age of all components,date installed(if known)and source of information:34 YRS,ORIGINAL,
OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:S PETER RD
SALEM,MA
Owner:FEENEY
Date of Inspection: AUGUST 30,2004
BUILDING SEWER(locate on site plan)
Depth below grade:26"
Materials of construction:Yeast iron_40 PVC_other(explain):_
Distance from private water supply well or suction line:N/A
Comments(on condition of joints,venting,evidence of leakage,etc.):THERE WERE NO SIGNS OF
LEAKAGE IN OR AROUND PIPE.SOILS WERE CLEAN AND DRY.
SEPTIC TANK:YES(locate on site plan)
Depth below grade: 17"
Material of construction:YESconcrete_metal_fiberglass_polyethylene_other
(explain)
If tank is metal list age:_is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:S'L X 5'W OUTLET INVERT na 50"=1000 eats
Sludge depth:20"
Distance from top of sludge to bottom of outlet tee or baffle: 4"
Scum thickness: 12"
Distance from top of scum to top of outlet tee or baffle: 5"
Distance from bottom of scum to bottom of outlet tee or baffle:2"
How were dimensions determined?ROD AND RULER
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):THE TANK WAS PUMPED.THE LIQUID LEVEL IS AT
NORMAL HEIGHT.THE INLET BAFFLE IS CEMENT.THE OUTLET BAFFLE IS SCH40 PVC AND IN
GOOD CONDITION.THERE IS NO SIGNS OF LEAKAGE IN OR AROUND AREA,SOILS WERE
CLEAN AND DRY.THE OUTLET COVER IS RAISED 6"UNDER GRADE.
GREASE TRAP:NO(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):_
Dimensions:
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle:_
Date of last pumping:_
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 8 PETER RD
SALEM,MA
Owner:FEENEY
Date of Inspection: AUGUST 30,2004
TIGHT or HOLDING TANK: NO(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain):
Dimensions:_
Capacity:_gallons
Design Flow:_gallons/day
Alarm present(yes or no),'
Alarm level:_Alarm in working order(yes or no):_
Date of last pumping:
Comments(condition_of alarm and float switches,etc.):
DISTRIBUTION BOX:NO(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):_
PUMP CHAMBER: NO(locate on site plan)
Pumps in working order(yes or no):_
Alarms in working order(yes or no):_
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 8 PETER RD
SALEM,MA
Owner: FEENEY
Date of Inspection: AUGUST 30,2004
SOIL ABSORPTION SYSTEM(SAS): YES(locate on site plan,excavation not required)
If SAS not located explain why:
Type
YES Leaching pits,number: 7'D X 6'H INVERT(a)60"
_Leaching chambers,number:_
_Leaching galleries,number:_
_Leaching trenches,number,length:
_Leaching fields,number,dimensions:
_Overflow cesspool,number._
_Innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):THERE WAS 6"OF LIQUID LEVEL IN PIT AT TIME OF OPENING.THERE WERE NO SIGNS
OF FAILURE OR BRAKEOUT,SOILW WERE CLEAN AND DRY.THE PIT IS PRECAST AND IN
GOOD CONDITION.
CESSPOOLS: NO(cesspool must be pumped as part of inspection)(locate onsite plan)
Number and configuration:_
Depth—top of liquid to inlet invert:_
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:_
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: NO(locate on site plan)
Materials of construction:_
Dimensions:
Depth of solids:_
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:8 PETER RD
SALEM A
Owner: FEElasnepY �! ��
Date of Insp n: AUGUS 30 2004
S
SKETCHOSEWAGE DI OSAL SYS
�ko Se
Provide a sk h of the sewag disposal system including ties to at least two perm nt reference landmarks or
benchmarks. ocate all wells it
100 feet.Locate where public water supply ent rs the building.
TI 5-601
Latch P.1-
Pull T►eS
A to Tl I$ 5
T3 +0 T i -?*,/
A SPI = iqt
Page 11ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 8 PETER RD
SALEM,MA
Owner: FEENEY
Date of Inspection: AUGUST 30,2004
SITE EXAM
Slope:FLAT
Surface water: NONE
Check cellar:YES
Shallow wells:NONE
Estimated depth to ground water 8'+(aourox)feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed:
YES Observed site(abutting property/observation hole within 150 feet of SAS)
YES Checked with local Board of Health-explain:INFO
NO Checked with local excavators,installers-(attach documentation)
YES Accessed USGS database-explain: MAPS
You must describe how you established the high ground water elevation: THE HOME HAS 4'SLAB
FOUNDATION WITH NO SUMP PUMP AND BASEMENT IS DRY.WHILE DIGGING IN YARD
LOCATING SYSTEM,THERE WERE NO SIGNS OF GROUND WATER AT DEPTHS OF 3'TO 4'.THE
LEACH PIT WAS PUMPED TO CHECK INFLOW AND THERE WAS NONE.THERE WERE NO SIGNS
OF ABUTTING PROPERTY'S WELLS OR WETLANDS WITHIN 150'FROM SYSTEM.
)iE
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\/ ? 577 Main Street.Suite 110. Hudson, Massachusetts )I749 E-Mail:
NE N TA L Telephone 978.562.4500 Facsimile 978.562.7255 wrenvironmental.com
O
oar X2004
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c
October 2, 2004 eOA OFH
ry
Wind River Environmental
163 Western Ave.
Gloucester, MA 01930
Board of Health Administrator,
This package contains the dump slips for the Board of Health from the field office
located in Gloucester, MA. This is the work we have completed.
If you have any questions, please feel free to contact our Director of Field Operations,
Brad Robertson, at 978-282-7315.
Thank you,
Miss Jillian H. aFl m
• Farm 4 -- System Pumping Record
Comnanwealth of Massachusetts
Massachusetts
System Pumping Record
I� I
I i
System Owner System Location
..•k(�nv -..k Pit+•t "rtiala y ljomc
dm. 4 ,.�y, ctyi 909 6alsystte 3t
.. Ba. 71", rri 5ahw, MA. 019711
d ,'7 'i .i'6L 1.50l x
Type: Em&Njeny Routine
Cesspool: w Yes Septic tank: No Yu
Date of Pumping: O Quantity Pumped: Ikms
System Pumped By: Wind Phar Env/ronmenfi/, LLC Perinit 9:
Contents transferred to:
Contents Disposed at:
ST s�
Date: Pamper Sigmta • _.
4
Condition of System/Other Comments
Dep Approved Form - 12/07/95
• Farm 4 -- System Pumping Record
Commw%vealth of Mlassachusetss
Massachusetts
System Pumoina Record
,:+fstem owner system location
l .rimary Hone
i 'nr ry 1.: r.,i.i V7 Tritexrval, Road
5.::1:r.r, Mr, 31�'+70 S�'. ac�. NiA, D7970
Kirk Jgfin
Type: Emergency Routine
Cesspool: No ✓ Yes Septic tank: No Yes
Date of Pumping: D ^ Z Quantity Pumped: 1, Gallons
System Pumped By: Wind Riney Environmental, LLC Permit#:
Contents transferred to:
Contents Disposed at:
Date: Pumper Signature:
Condition of System other Comments
IE
I
Dep Approved Form - 12/07/95
Form 4 -- System Pumping Record
CommonwsaMh of Massechusetss
Massachusetts
System Pumoim Record
System Osmer System Location
:t�:n�'1•;i ' . F.7sta.ur.ai)t - 41andy's faC1332
73^ et.on Rasa. F, iv_t'aclise Pd
hie, r_fc,i,i, MA, 01885 S.tlr "QA, Q2379
Type: n EmugeKy Routine
Cesspool: Mo � Yes Septic tare: No Yes
Date of Pumping: lJ`1..ZL{.,. �l(..� Quantity Pumped: Ada 6allons
System Pumped By: Wind Over Envinaunentai, LLC Permit#;
Contents transferred to:
I
Contents Disposed at:
IDate: Pumper Signature;
Condition of System/Otlw Comments
be Approved Form - 12/07/95
Form 4 -- System Pumping Record
Commonwealth of Massochusetss
Massachusetts
System Pumoina Record
System Ower System Location
Coar j .�iwib F.._.tu�e [IrTite
41' I.nzaye+.te Fxx&-t 411 LafayQtte Str!4at
rA '11+70 Sa;am, NA 01970
F ;p 0753 (5,3,3) '78•-0?5i r.
TelEmergency Routine
D fl: Plo Yes Septic tank: w =Yes
Pumping: Quantity Pumped: Gallon
System Pumped By: end RAW Envhwmnenfa/, LLC Permit M
Contents transferred to:
Contents Disposed at:
Date: /�d0/ Pumper Signature:
Condition of System/Other Comments
Dep Approved Form - 12/07/95
Form 4 -- System Pumping Record
Commonwealth of Mossachusctss
Massachusetts
System Pumnino Record
System Owner System.Location
r'C'Ur"_ry Cl. ibY.z.rncai.; COwItxy Club
Ker .:w}na St K�xmuc�i t;
1.970 5:,1^14, PLA, 01970
x 978)-745-f PI9 x
Type. EmmWwy Routine .�
pti
Cesspool: Isla Yes Sec tank: W QYes F
Daft of Pumping: Quantity Pampad: 04= Gallons
rl�--
System Pumped By: Wmd Over Ehmwa ren M/, LLC Permit#:
Contents transferred to:
.elt
Contents Disposed at: Sks's J
z Z�u
Date: - pumper Signa
Condition of Syatem/Other emments
Dep Approved Form - 12/07/95