HomeMy WebLinkAboutSeptic Pumping Slip - 1755 OSGOOD STREET Commonwealth of Massachusetts
City/Town Town of W t in coy ti
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DEP' has provided this form for use by local Boards of Health.-...�'l ys - u a ing Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 9. System Location:
forms on the
computer,use � Vi
only the tab key 4ddres�s _„
to move your 1\1, 4XY 1 d
cursor-do not City/Town State Zip Code
use the return
key' 2. System Owner:
° i 1
� ,f&
Name
rerrn Address(if different from location)
City/Town Slat .-, rry( Zip Code
(4 w
we
Telephone Number
B. Pumping Record
1. Date of Pumping 'L
Date i — 2. Quantity Pumped: gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes B2/No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
0,(4--'
6. Sys em Pumped B
Na IVehicle License Number
{''° t
Company
7. Location where contents were disposed:
Signature of Hauler Date f
http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
1`
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: ..J 117,o
7SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(e xample. left front of house)
DATE OF PUMPING: QUANTITY PUMPED
;L GALLONS
CESSPOOL: YES SEPTIC TANK: NO YES
NATURE OF SERVICE:
ROUTINE , E ERCENCY OBSERVAT IONS:
GOOD CONDITION ,..- FULL TO COVER
HEAVY GREASE BAFFLES IN PLAUE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS
FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
.b
SYSTEM PUMPED Y: oucy's Sewer Servic e, lite.
830 Livingston Sti-ect
Tewksbury, MA 0 1876
COMMENTS:
CONT NT'S 'I" SF'E a T"(.I s,
�t
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
4 z,
4 Q-6-3-
) 5 ffm OWNIIR & ADDRESS SYSTEM LOCATION --- __
(example; ICf( from or house)
Wei
U \'I C OF PUMPING. w ) ° (QUANTITY PUMPED / -()e C' L L���
C. i::;.;I'00L: NO YES SEPTIC TANK; NO YES Lam'
-\TUBE OF SERVICE; ROUTINE EMERGENCY
FRV:\T10NS,
COOD CONDITION, FULL TO COVER
HFAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK.,
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER PU HFR (EXPLAIN)
PUMPED 0Y:
c u I FNTS.
UN H !'IZANSFEIZIED TO