HomeMy WebLinkAboutSeptic Pumping Slip - 67 CRICKET LANE 3/29/2016 Commonwealth O Chu ett
City/Town of NOV 4, 20(4"
System i , r
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DEP has provided this form for use by local Boards of Health. Other farms may be used, but the
infom7ation 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 ward of Health or other approving authority.
A. Facility Information
Important:
When filling out y" c~' s
forms on the 1. stem Loction m ---- -- - -- - -- — � .
computer, use Address V'�
p --
only the tab Ivey
to move your - __---
cursor-do not s — Zip Cade
use the return tag
key. 2. System Owner:
Name
Address(if different from location)
Ctkyn own --- ---— — — state -- ——— Zip Cade - ---
_.c -- --
Telephone Number
B. Pumping Record
1. Date of Pumping Date - 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): -- — --
4. Effluent Tee Filter present? ❑ Yes Na If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6. Syste Pump "y:
Name Vehicle License Number
Company
7. Location w ere contents were used:
signature o a r [late
t5form4.doc^06/03 system Pumping Record•Page 1 of 1
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A, R'E(--,EIVED
TOWN OF
SYSTEM PUMPING RE CO D[J' (3 2 ?�005
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DATE: i . , � A
ID
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
�( e,
(example: left front of house)
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DATE r w ADATE(DE PUMPING: QUANTITY ITY P P°EID e GALLONS
L°
CE P®cD n NO YES _. SEPTIC TANK: NO YEs
NATURE, OF SERVICE: I2OUTI + EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVE'R
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEI AC14FIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OT +R(EXPLAIN)
SYSTEM PUMPE ID BY. Bateson Enterprises, Inc.
COMMENTS:
NTS:
o �
CONTENTS TRANSFERRED Tire G.L.S.D Lowell Waste
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
ATie /) /
ss
SYSTEM O dE SS SYSTEM LOCATION
(example: left front of house)
,
t i
v
+f, w,i ;t;j, ,i ;t iii ',,`• ,.,
.ANTE OF PUMPING r � .� �,}� QUANTITY PUMPED GALLONS
SS , L: NO YES SEPTIC TANK: NO YES /
NATURE..�� SERV ICE:. CE .OITINE EMERGENCY
SE VATI NS: _
QI� (I�1L)ITICII� ifs _.., FULL TO COW'R
�
EA ASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS YO T ER (EXPLAIN)
SYSTEM PUMPED Yd.
It
+
COMMENTS-* P
0 TO
ENTS TRANSFERRED
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