HomeMy WebLinkAboutSeptic Pumping Slip - 35 ROCKY BROOK ROAD 4/7/2016 Commonwealth of Massachusetts 1
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x City/Town of
4 M
ytern Pumping Record
Form 4
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DEP has provided this form for use by local Boards of Health. Other farms may��e'usod
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
JUN 2 2 ?009
DEP has provided this form for use by local Boards of Health. Other for r ns ma;be us ed but the
information must be substantially the same as that provided here. Befo &, '*WtP your
local Board of Health to determine the form they use. The System Pumping- ord-must-be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left front, left rear, left side of house. Right front, right re( , r2ight side of house.„
forms on the
computer, use
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
City/Town Statq Z' Code
D-,
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Q Cesspool(s) B-ge�pfic Tank 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present? Lj Yes U-No" If yes, was it cleaned.? [I Yes Ll No
5. Condition of System:
V7V) q- 42A
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
O.L.&D Lowell Waste Water
fig n a u r Ve—of H 4ur Date
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/*
M OF 11 INA PIAM: CIS (,)(JM1flTf'v PUMPF"t):
",eptic Tank: NO V)�S
04AHMEMSERVI(jo ROMINE, V/
(A ISIM Vill IMS:
M K)D C UNDUHM R"A. TO MV GR
HEAVY GREAM BARMS M WICL
RMNIBACK
MY)CARRYOVER M1WR FXPLATI
)4m and by Wup/-
4/P/
'TOWN OF NOR'TH ANDOVER
SYSJ'EM PUMPING RECORD
DATE: - //
STEM I M OWNER & ADDRESS � S�'S"1 I.NI L()C:'ArI`I()N
(example: left fro►it of house)
D:%Tf,' OF' PUMPING: �e� . QUANTITY PUMPED
�>L: N O �Y , °'°' '
C'I:�SP()C � E�;S SEPTIC TANK: NO YF,S �
N'ATURE 0 F SERVICE: ROUTINE, EMERGENCY
O13SI'RVAT10NS:
GOOD CONDI'T`ION PULL TO C'OVI?R.
---
HEAVY BAFFLES IN PLACE
ROO'T'S LEACIIPIELD RUNBACK
EACESSIVL SOLIDS FLOODED
SOLIDS CARRY0VER OTHER (EXPLAIN)
S`,'STE,N/1 PUMPED BY:
C`O.4INIENTS: