HomeMy WebLinkAboutSeptic Pumping Slip - 202 LACY STREET 3/30/2016 Commonwealth of Massachusetts .
City/Town of RECEIVED
System Pumping card a 3 NUiP
r` Form 4
a
DEP has provided this form for use by local Boards of Health, Other forms � U#j6A . •
information must be substantially the same as that provided here. Before using°f r�is 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 within 14 days from the pumping date in
accordance with 310 CMR 15,351.
A. Facility Information
Important:
When filling out 1. System Location:
farms to the ``1C 1 W c , 451
computer, use t�C r� �j.
only the tab key Ad ire
to move your
cursor-do not CitylTow n State P"U%&
use the return
key. 2. System Own r: _
Marc to rn�� .n _ 1c����ti ��CJ
Name
ryas Address(if different from location)
Cityrrown State Zip Code
999 6
Telephone Number
B. Pumping Record
1. Date of Pumping Date+ ` � 2. Quantity Pumped: Gallo ns
,--,r
3. Type of system: El Cesspool(s) [a/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ other(describe): [O/
No Effluent Tee Filter present? El Yes U No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Gc)oj —
6. System Pumped By:
Name Vehicle License N mber
Ah ill
Company —
7. Location where contents were disposed:
_ a r,n
� ,
5ignetu of Hauler MA 01938
Signature of Receiving Facility Date
t5form4.doc,03/06 System Pumping Record•Page 1 of 1 /"'"
Commonwealth of Massachusetts
V City/Town Of NORTH ANDO ASsACHUSETTS
ystem Pumping Record
Form 4
i
DEP has provided this form for use by local Boards of hlealthj Thrr 6 System Pumping-F1ecord must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the w cx
computer,use
/ — -- ----
only the tab key Address e�
to move your y,J 8 (", Cr 0 G
cursor-do not City/Town State Zip Co- e
use the return y
key. 2. System Owner:
�• n
rob V t✓w ( (sl � — --- —
j
Name
erwn Address(if different from location)
City/Town ---- -- State ---- --- Zip Code -�-
°~
Telephone Number
B. Pumping Record
1� Date of Pumping -pate 2, Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): -- - - — -
4. Effluent Tee Filter present? ❑ Yes ❑�o 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 of Hauler --- --- — --- -Date ---- --- - ------
http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
..�.. RECEIVED
�
TOWN OF NORTH ANDOVER OCT 01 5 2()(M
`T A ,W3M 7WN!~R DDiiF S SYSTEM LOCATION
, ` .
141i) , ,� ?""
DATF OF PUMPING:
✓�, � .,, . ... .._QUAN`N"ITY PUMPED
k SSE'CX�h,: NC7 YEWS
...,.__.. .. �✓` Supcic f'rxrrk: NO YE.;w
NA PURE✓ OF SERVICE: ROUTENE ,,
...._.. .__..EMERCiN:NCY
OBNERVATIONS:
GOOD CONDITION El�l FULJ. 'ro C;OvE.R
HEAVY OREASE _ BAFFLES IN PLAC;l,
ROOTS LEAGW,FIELD RUNBACK ...
FFXC;E:,SSIVE SOLIDS FLOODED
SOLID CARRYOVER_._... _.OTHER EXPLAIN
SyaWrtr Humped by .... � .. . � 1/�
t'UMME:N I�5
t'VN I EN I'S rKANSI-'hRREIa 10 ). ��
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�I,'1ZANS'f Gl�l�l✓D 'r'U�
TOWN OF NORTH ANDOVER
SySr rEM PUMPING RE CORD
til STEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
(67L
o,�2
A10.
QUANTITYPUMPED2,f
I 5).S P 0 0 L: NO 1,, YES SEPTIC TANK: NO YES
A'FURF OF SERVICE: ROUTINE EMERGENCY
-I
Ufa. F R V/A T 10 N S:
GOOD CONDITION FULL, TO COVER
HEAVY CREASE BAFFLE'S IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER 0AHER (EXPLAIN)
")"I'L.M P U M P E D B Y:
1 t ,
c,u1I m FN TS: s
B-6
0 N' TI Z A NS F E I Z I Z ED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING
DATE: d
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example:p left front of house)
2 z U c
DATE OF PUMPING: QUANTITY PUMPED J ! cUC) GALLONS
, ,,\ts k 0 6b
CESSPOOL: NO JYES SEP'TIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES ICI PLACE
ROOTS LE AC !IELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: � �
Comm weal i of Massachusetts
assachusetts
Sy tem Putuping Record
System Owner System Location
Date of Pumping: �— (luahtity Pumped: allons
Cesspool:'es pool: No M Yes L.J Septic Tank: No Yes
System Pumped by: $ct reodo rt�aea License #
Contents transierrred to : Greater Lawrence Sanitary District
Date: Inspector: