HomeMy WebLinkAboutSeptic Pumping Slip - 45 BEECHWOOD DRIVE 2/16/2016 Commonwealth of Massachusetts �
� City/Town of North Andover l ,r��w F �a� ��
��v�N t, 0Pi Fi i i i i
System Pumping r
Form 4
DEP has provided this form for 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 forms 1. System Location r,.
on the computer,
use only the tab
key to move your Address
cursor-do not North Andover Ma _
use the return —. –
key.
Gityrfown State Zip Code
2. System Owner:
tab
-....L ,
Name
reran
— --
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ecor
..
1. Date of Pumping d Date r 0 2. Quantity Pumped: Gall ns
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - -
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
l
6. System m Pumped
.
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
thwarts Mill Bradford, Ma 01835
Signature oi:t�1 er �� Date
— -
Signature of ceivi' g FIi y Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth cif Massachusett � _... �
M City/Town of NORTH ANDOVER
MASSACHUSETTS
System Pumping Record 4
a� Form 4 MAIN OF NORTH ANi)t.7VGr`R
HG AL"TH DEFIAR"t"N L:NT
DEP has provided this form for use by local Boards of Healt . `h' Sys em"'PU'ping ecord must
be submitted to the local Hoard of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: J
forms on the fb'& �t 0 0 6 ��
/
computer,use `� t V
only the tab key Address
to move your t�1
cursor-do not City/Town State 'Zip Code
use the return
key. 2. Sys Owner:
sFw"J� la8
Name
Address(if different from location)
City/Town State Zip Code
T leT ephone Number
B. Pumping Record
' 260c)���
t � �
1, Date of Pumping � ��� 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Sys m Pumped By:
N e Vehicle License Number
Company
7. Location where contents were disposed:
Lcz)
s
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doa 06/03 System Pumping Record•Page 1 of 1
TO OF NORTH ANDOVE
SYSTEM PUMPING RECORD
SYSTEM OWNER & ADDRESS
,,I SYSTEM LOCATION
y (example: left .front of house)
DATE OF PUMPING: QUANTITY PUMPE1)
GALLONS
CESSPOOL: NO YES
_________ SEPTIC TANK: NO — YES
NATURE OF SERVICE: ROUTINE
hM ERG E NCY
OBSERVATIONS:
GOOD CONDITION °� FULL TO COVER
HEAVY GREASE ---
ROOTS -- RAFFLES IN PLACE ---
EXCESSIVE SOLIDS �� LEA I) RUNBACK
SOLIDS CARRYOVER—�' FLOODED
OTHER (EXPLAIN) ---
--___ _
SYSTEM PUMPED BY:
'OMMENTS:
ONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: /Ok-)h)z
—
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: 0m ra / QUANTITY PUMPED j GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES –= �-
E
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:
COMMENTS:
CONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRE r SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: QUANTITY PUMPED,:'° -'4- -',) 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:
COMMENTS:
CONTENTS TRANSFERRED TO: