HomeMy WebLinkAboutSeptic Pumping Slip - 427 WINTER STREET 3/28/2016 Commonwealth of Massachusefts
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System Pumping Record M14
e
Form 4
o Nuf4TH O
DEP has provided this form for usezby local Boards of Health tP ,r � � � � the
information roust 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/Right front of house, Left/ 1@ $rear of hou , , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Righ roar Of building, Under deck
Address
M
City/rowr► ete Zip Fade
2. System Owner: r
Name'
Address(if different from location)
City/Town ' State, '`, > cede ,
Telephone Number
r
i,
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
. Type of system: Cesspool(s) eptic Tank El Tight Tank
Other(describe):
4. Effluent"fee Filter present? "des P No If yes, was it cleaned? El Yes El No
5. Condition of.System:
6. System Pumped By:
Neil Satesbn F5321
Name Vehicle License Number
Sateson Enterprises Inc
Company
7. Location ere contents were disposed:
ISign S. Lowell Waste Water e hlaule C1ate
t5form4.docm 06/03 System Pumping Record-Page I of I
w a
Commonwealth Of Massachusetts
City/Town of
System Pumping Record
Facility Information:
System Location:
Address
LAIN 81 _�Lv�c A t
City/Town State Zip Code
System Owner:
D , L) /�o 4;-;. a
Name:
Adress (if different from location of pump)
City/Town State Zip Code
Telephone Number
Pumping Record
Date of Pum in
p . ZI Quantity Pumped f�r C`,, gallons
Type of System�Septic Tank G°rease Trap Other (what)
System Pumped by:
Company: ROOTER-MAN 46 Portland Street Lawrence, MA 01.5343
Location where contents were disposed:_
Signature of Hauler Date -
Commonwealth of Massachusetts
Im =
City/Town of NORTH ANDOVER MASSACHUSETI,
System Pumping r � .
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record mint
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out System Location:
forms on the
computer, use c. ..
only the tab key Address— r r — --- — - ---- ---------- ----- -
to move our
cursor-do not 1 r —
use the return City/Town State Zip Code
key. 2. System Owner:
Name ----- --- � „„ � �� -------- -- --------
eum ° Address(if different from location) -- -- — -- ——
City own
y � Sta -
„ Zip Code
((MA ." 1 �".011(w Telephone Number --
el
. eta ping."'Record
1. date of Pumping �� — -- --= --
Date 2. Quantity Pumped: Gallons -
3. Type of system: ❑ Cesspool(s) J9SeP4c,Tank ❑ Tight Tank
❑ Other(describe): -- — — ---- ------- ---
4. Effluent Tee Filter present? ❑ Ye °_-... If yes, was it cleaned? ❑ Ye °o
5. Condition of System:
6. y 7t7ll u m ed B :f r al)e..
P
Name - -- -
_
�� a Vehicle License Number..
7. Company � ��
Location where con,ents were; d' sed:
Si natur�
g Haul Date -
http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record<Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
STEM OWNER & ADDRESS SYSTEM LOCATION --
(=,lmple: lef( iron( of hose)
i
U ETC OF PUMPINC: f :,w QUANTITY PUMPED L"" '�
0/aL !_c
:..)SPOOL: NO YES SEPTIC TANK : NO YES
� ATURE OF SERVICE: ROUTINE,/\ EMERCENCY
FRV.:\T10NS,
GOOD CONDI'T'ION. FULL TO COVER
HEAVY CREASE BAFFLES IN PLACL.
ROOTS LEACHFIELD RUNUACK
CXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O�FiF:R (EXPLAIN)
'M PUMPED BY:
-----
j
� r
U I:'NTI TIZANSfEIZIZED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
1
SYSTEM LOCATION S EN OWNER & ADDRESS
-- - -
--
(example: left front of house)
1) 1 E OF 1)UM1)1NG ' QUANTITY PUMPED GALLC .A,,)
('1'�)SI'O0L: NO w_ YES SEPTIC TANK: NO YES _
N.,\TURE OF SERVICE: ROUTINE EMERGENCY
O1351'l�N'ATI0NS:
GOOD ('0 N1)1'1'1ON w ' FULL `I'O C'OVEIz
1-1LAVY GREASF 13AFFL,ES IN 1)L,AC'E
ROOTS 1,1?ACLif^"IF.LD RUNBACK
EXCESSIVE SOLIDS FLOODED --
SOLIDS CARRYOVER OTHER (EXPLAIN)
PUMPI?D 13Y:
('O 'Tl, N'P,)' T]ZANSF"FlZfZED TO: