HomeMy WebLinkAboutSeptic Pumping Slip - 40 EQUESTRIAN DRIVE 2/25/2016 Commonwealth of Massachusetts
a 6(� city/Town of
� System Pumping Record
4, Form 4
DEP has provided this form for use by local Boards of Health. Th SySIN j iw ngi' tecor mu<.
be submitted to the local Board of Health or other approving auth rity.
A. Facility Information
Important; I 1F Y'vIOl T� Ak A Wl._.,
When filling out 1. System Location: 811 ( i"..w4 lr iei f C C��,..........N
forms on the f
computer, use �� ❑ .; r .,, °° � .��
only the tab key Address
..
your
Cit !To— _
cursor�do ot �°"�_ � ��"'�� ✓'��.�'�,�,✓� — _._ _,..� �° � _
use the return City[Tow
key. State
Zip Code
2. System Owner: r
Name
a u
—— Address(if different from location)
City/Town
State Zip Code
Telephone Number _
B. Pumping Record ---- - - - -
1. Date of Pumping
Date � _ 2. Quantity Pumped: Gallons
..,
3. Type of system:yp y ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System:
6. jSyem' Pumped By: .
Name
— Vehicle License Number
Company
y�
7. Location where contents were disposed:
/ ature of Naul� Date http://www,mass.gov/dep/water/approvals/t5forrns,htm#inspect
t5form4.doc,06/03
System Purnping Record - Page i of ?
0
rowN OF NORTH ANDOVER
i SYSTEM PUMPING IECC)Ri)
SYSTEM OWNF;R & ADDRESS
SYST'E:M LOCAT"TC)N
r .
DATA OF PU INQ;e..._..1. '-jj pi�.._,__. .�_Q1.1ANTiTY PUMPED;
� ._C _.. nT .
C E,SSPCX)L: NO YEAS
�.,..., .. ,. .._ .. Septic Tank.: NU, Y ES
NA rUREs OF SERVICE: Rou'rl.Nk..._,. ._.,.BmERC)k;NC'ti'
OBSERVATIONS:
D CONDITION � FULL '
I'U(,OVER
HEAVY OREASE 13AJ7FLES IN PLAC;I,
ROOTS _. _ LEACH E-LD RUNBACK ......
I3XCUSIVE, SOLIDS — FLOODED
SOLID CA YOV'BR A^.... OT'MER EXPLAIN
�y®tvrn Pumped by
CPO.-.0
COMMENTS,
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TOWN OFj ANDOVER
SEPTIC SYSTEM SERVICING
REPORT
Date:--
Homeowner: 7.�____
Street �J Pumper
Phone Address: {.
Phone
Nature (]f Service:
Routine
Emergency
Observations : Good Condition
Full to Cover
Baffles in Place _
Leachfield Runback _
Excessive Solids —
Heavy Grease --
Roots —
Other (Explain)
Description-. of Work:
Comments : r,