HomeMy WebLinkAboutSeptic Pumping Slip - 15 FOREST STREET 3/7/2016 Commonwealth of Massachusetts
City/Town of NORTH ANDOVE ACHUSETTS
System Pumping Record
Form 4
...........
DEP has provided this form for use by local Boards of Health. Th Sys I ecor must
&"
be submitted to the local Board of Health or other approving auth rity.
A. Facility Information (J F(T i I A N E�CAU
Important: iE AJ,1 V-1 DEPARTII,AE
When filling out 1. S stem Location:
forms on the
computer,use
only the tab key Aqdress
to move your
cursor-do not
use the return 'City/Town State Zip
key. 2. S tern Owner-
Name
------------ —-----
Address(if different from location)
City/Town State ode
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) O'Septic Tank ❑ Tight Tank
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ 40 If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. 'Pstern Pump ' 3
T)
Vehicle License Number
Company 1
7. Location where contents were disposed:
Sign of Hauler Date
http://www.mass.gov/dep/water/approvaIs/t5forms,htm#inspect
t5form4.doc•06/03 System Pumping Record-Page 1 of I
i
TOWN OF NORTH ANDOVE R
SYSTEM PUMPING RECORI)
DATE. < C
SYSTEM OWNER & ADDRE SS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: / (QUANTITY PUMPED L5(Y) GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE__X_ 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: ( c1("; r° ��,�� .0 ` c &lw c...
COMMENTS:
CONTENTS TRANSFERRED TO: . ��
BORACZEK'S
SEPTIC & DRAIN SERVICE
10 Belmont Avenue, Haverhill, MA 01830
(978)374-8803 & 1-(603)329-6005
COMMONWEALTH OF MASSACHUSETTS
P-0owe-it- -MASSACIIUSETT
SYSTEM.PIUMPING RECORD
SYSTEM OWNER: S Y ST EM LOCATION:
( cv(L", -
co�14U.Aj�o�'A '�k;.)
/V
DATE OF PUMPING: QUANTITY PUMPED: GALLONS:
cesspool:No-----Yes-_Septic Tank:---No--Yes
SYSTEM PUMPED BY, BORACZEK'SSEPEIC e.: DRAIN,VERII[CE
Contents Transferred To-.— MOO
DATE: INSPECTOR: