HomeMy WebLinkAboutSeptic Pumping Slip - 17 LACY STREET 3/29/2016 Commonwealth of Massachusetts
City/Town Of NORTH ANDOVE 9 �
System u in g Record w w
Form 4
Y Y
DEP has provided this form for use by local Boards of Health. The System PumpW#fW rd must
be submitted to the local Board of Health or other approving authority._ r r"UME.N
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use
only the tab
to move your Address Ct J
use the return City/Town State r / Zip Code
key' 2. System Owner:
tab _ �
t'
Name
irhun `
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping /0/ 6 ... 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ",R Septic Tank ❑ Tight Tank
❑ Other (describe): -- —
4. Effluent Tee Filter present? ❑ Yes R No If yes, was it cleaned? ❑ Yes ❑ No
5, Condition of System:
6, System Pumped )By:
Name
Vehicle License Number
Company
7. Location where contents were disposed:
Signature�
g e o e �Hauler Date
http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
T(0WN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
�l SI'EM OWNER & ADDRESS SYSTEM LOCATION
(example: f( front of house)
c
Y k �
U:v'rE OF PUMPING ���� ��' �5 QUANTITY PUMPED °der G'ALL(�
.51'OOL: NO YES SEPTIC TANK: NO YES
MATURE OF SERVICE: ROUTINE EMERGENCY
(m.> ;R Y.�\TI ONS:
GOOD CONDITION. FULL TO COVER
HFAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS , FLOODED
SOLIDS CARRYOVER Njl-# ER (EXPLAIN)
i
>ti >T M PUM PC, BY:
Um lylFNTS:
U "I ('.N'I'S TIZANSFEIZIZED TO: