HomeMy WebLinkAboutSeptic Pumping Slip - 97 SAW MILL ROAD 3/25/2016 Commonwealth of Massachusetts
City/Town of
Pumping YS
r
For 4ma i"�C"6F�
DEP has provided this form for use�by local Boards of Health. Other forms h,�y,j$efused, but tyre
information must be substantially the same as that provided here. Before using.this farm, 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
1. System Location: Left eight front of house, eft/Right rear of house, Left/right side of house, Left/
Right side of building, Lem Ig t r6rit-of-bulidirig, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ' State 1 p j_ ip Code
Telephone Number
B. Pumping Record w .
1. Date of Pumping 2. Quanta Pumped:
Date ., Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes IGo if yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location here contents were disposed:
�L S. Lowell Waste Water
Sign t e Haule Date
t5form4.doca 06/03 System Pumping Record-Page 1 of 1
Commonwealth Of Massachusetts
City/Town ®f
a System Pumping Record
.Y` Fora' 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.
A. Facility Information
1. System Location: Left Ight front of fjous(0, Left/Right rear of house, Left/right side of house, Left/
Right side of building, LRfight ffront of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Citylrown °' ,
� State Zip Code
arw '� Telephone Number " [
1
B. Pumping `± i
1. Date of Pumping '5
Date 2. Quantity Pumped: Gallons s'
3. Type of system: ❑ Cesspool(s) ❑ eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
aIn'S. Lowell Waste Water
Sign toe Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: ,.
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: .) Lz j v 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 LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN) ;:
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: 0 �