HomeMy WebLinkAboutSeptic Pumping Slip - 60 ROCKY BROOK ROAD 3/8/2016 p ,lb
Comm' onwealth of Massachusetts
City/Town of NORTH ANDOVE
ACHUSETTS
System i Record
Form 4
"DEFIAFMAENT mub!'�wu�IlWgVtiNyW ,�fr Gi�r rwuwaammanu?'mum DEP has provided this form for use by local Boards of Health. Th Pumping Reco must
be submitted to the local Board of Health or other approving auth ,A. Facility Information Important: DI� EFIAV��° t'A"�'E T when filling out 1. System Location: ��������"�� �� ��"
forms on the
�
computer, usey
P
on ly the tab key Address
to move your City/Town lfown�
cursor-do not
use the return y State Zip Code
key. G. System Owner:
VQ Y .. M
Name — -- --)('k "
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: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
tl
❑ Other(describe):
4. Effluent Tee Filter present? Y
Yes ❑ No If yes, was it cleaned? Yes ❑ No
�. 5. Condition of System:.
6. System Pumped By:
. . .–Nam.e.. Vehicle License N be�r
„
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF
SYSTEM PUMPING RECORD
DATE:
" `�"`2_ 61
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example; left front of house)
,Aj vQ(zw- OF
DATE OF PUMPING: , , QUANTITY ITY PU ELI : � � GALLONS
CESSPOOL: NO ✓�__ YES SEPTIC TANK: NO YES_tee
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHE R(E LAIN)
SYSTEM PUMPED BY. Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: