HomeMy WebLinkAboutSeptic Pumping Slip - 102 WINTERGREEN DRIVE 3/2/2016 Commonwealth of Massachusetts ��I III
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Gity/Town of-
Sys-Le m Pumping Record
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I'acifity In-1"or ation:
System Location:
„ , r...
Address --
__ �
City/Town State Zip Code
System Owner.
Name:
Adress (if different from location of pump)
City/Town State Zip Code
Telephone Number
Pumping Reco.-rd
Tate of Pumping s _ Quantity Pumped_ �� ��� gallons
Type of System__ Septic Tank Crease 'Frals Other (what)
S),stem Pumped hy _„ � .. ... ....�..
m -
Company: DOTER-MAN 46 Portland Street Lawrence, t`�.�A 01143
Locationn where contents were disposed;
Signature of Hauler— �.. � Date
Commonwealth of Massachusetts
City/Tow of
, System Pumping Record
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TOWN 001 NOWN AMNPPI�W�
H
FAITH rHAVARI
Facility Information-
System Location:
.Address
Cit.y/Town State Zip Code
System Owner:
Adress (if different from location of pump)
City/Town State Zip Code
Telephone Number
Pumping Record
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Date of Pumping Quantity Pumped gallons
Ty of System
pe
__4jSeptic Tank-Grease Trap Other--(what)
System Pumped by: L'/( 't v
Company: ROOTER-MAN 46 Portland Street Lawrence, MA 01 843
Location where contents were disposed:
"4
onature of Hauler Date
Commonwealth of Massachusetts A U 15
City/Town of M N(IR I
System Pumping Record
Facility Information:
System Location:
Address
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,J
C citv4/Tv
Ity/T wn State Zip Code
System Owner,.,,
Name:
Address (if different from location)
�City/Town State Zip Code
Telephone Number
Pumping Record
Date Of Pumping
Quantity Pumped gq_llons
Type of System: Septic Tank Grease Trap Other
System Pumped by:
company: Rooter-Man 12 East Dracut Road, Methuen, TVIA 01844
.
Location where contents were disposed:
Signature of Hauler 1) ,"1, zlz KJ/' Date:--
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i Ali� I I)h PA (M f i.Y
DEP has pr'c��� ed tots ��c MI fiat•u9b by local Boards of Health. The Sy'�t��rl� �iYliSiii��t��ccaC�G1..Must.���i
bo SUM,r Od to the 10GH1 Board of l°lt!W or
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Mon Moo out 1. SySM L riticart. �
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Of PLifnping 4r�Y� 2, QLMWl tfty' PulllPed: -
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Type of sywaaj: 1:71 ces�5pooqs) P El Tight Tank
ED r_an' r��,rilal:
xhe is
4. EirWer7t rOO Mer Presant? (-J 'Yes ��1 ttii�, � "---------
If `r'P-s ❑ No
C.oriditicin of System
SYMm Pumped By
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Symern Pumping Read,p,,, 'I crr
,
Commonwealth Massachusetts
a
pity/ OVVr , ry C
System Pumping
Form 4
DEP has provided this form for use by local Boards of Healt],
I. Oche fi � rrr`py b �W ek ; but th
information must be substantially the same as that provided here. B for using this Writ 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.
A. Facility Information
When filling out 1. System Location:
forms on the computer,use -- / .% � ,/6 / . /C
,C r
n __,Address
cursor ed r
only the tab o noty �A - t7(/ - ...
use the return City/Town State Zip Cade
key. 2. System Owner:
OQ Name
------ - -------- -------
0"MD Address(if different from location)
City/Town — - -- State Zip Code
Telephone Number
B. Pumping cord
1. Date of Pumping n e ' 2. Quantity Pumped: Gallons
°
� , '
3. Type of system: ❑ Cesspool(s) ��' Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ® No
5. Condition of System:
6. System Pumped By:
Name.. �.. �
Vehicle License Number
Company
7. Location where contents were disposed:
1
ignature f'Haul r" date
t5form4.doc^06/03 System Pumping Record o Page 1 of 1
TOWN OF NORTH
SYSTEM U I
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
..
(example: left front of house)
IT
DATE OF PUMPING: —5/ c QUANTITY PUMPED / �/ 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 LEACITFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY
COMMENTS:
CONTENTS TRANSFERRED TO ,,., '
TOWN OF NORTH ANDOVER
SYSTEM PUMPING
DATE: 1 b
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: °' - QUANTITY PUMPED 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: