HomeMy WebLinkAboutSeptic Pumping Slip - 524 REA STREET 4/12/2016 Commonwealth f Massachusetts
P
City/Town of U
Pumping System r
Form 4 jLjN %P 0 Z;—1 0 c
DEP has provided this form for use by local Boards of Wealt . r;f0 m °I but the
information must be substantially the same as that provided ere t ) ,check with your
local Board of Wealth to determine the form they use. The System Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Facility Information
Important:
When filling out 1 y "�y. ��.�.�.._..
forms on the
stm oca t. n ,
computer,use _
only the tab Ivey Address
to move your
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
VQ Name - --
reon Address(if different from location)
City/Town State II Ce
Telephone `Number
B. Pumping cr _. t.
Y� w„
1. Date of Pumping Date 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
.. �
Namd Vehicle License Number
.,
� ce P
Company
{. ontents
we ° Isposed:
7. where c
//X",
q p nµ
Sig to auler Date
t5form4.doc-06/03 System Pumping Record a Page 1 of 1
Commonwealth of Massachusetts _ �
City/Town of I
System umpin c r /'��I�� <'Iff1�i
r
Form 4 �
DEP has provided this form for use by local Hoards of Health.- The System Pumping Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When computer,use
y
formes onlltheout System -
--- — ---- ---------- ---
- -only the tab key Address
to move your
cursor-do nok Cit y!town - —
use the;return Mate Zip Cade
key. 2. System Owner:
Name — -- -- -
Address(if different from
Citylfawn Stale Z p Code - -
Telephone Number
urmp'ng Record
1. Date,of Pumping gate -- 2. Quantity Pumped: - - -
Gallons
3. Type of system: ❑ Cesspool(s) '-0-1S�ptic Tank ❑ Tight Tank
❑ Other(describe): - - ------------- --"_ ---
p ❑ Yes ,❑ No
4; Effluent Tee Filter• resents If yes, was it cleaned? ❑ Yes ❑ No
I
5. Cand itio of�System:
6. System umped�$y;
NamAny
� _._ ------
Vehicle license Number
Com
contents di? ed:
7. Lacatian hrere can e ere i
� vy �sl
Sin ure auler ate -- -
http://www.mass.gov/dep/wa er/approvals/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
�ac�
DATE OF PUMPING:`1`1"1-0 r, QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES _
NATURE OF SERVICE: ROUTINE ✓ EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFWLD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: q1 Yc15�0 01
COMMENTS:
CONTENTS TRANSFERRED TO:
TOWN OF
SYSTEM'PUMPING "CO"
DATE:
S STE
r')�Z�uv
O NER& ADD RE SS SYSTEM LOCATION(example: left front of Douse)
4„w
Roi s
DATE OF PUMPING: QUANTITY PUMPE II : "° GALLONS
CESSPOOL: NO YIDS SEPTIC TANK NO _ YES
NATURE OF SERVICE: ROUTINE, EMER ENCY ___
OBSERVATIONS:
GOOD CONDITION FULL TO COVE'R
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTHE R(EXPLAIN)
sYs +m Pumprim BY: Bateson Enterprises, Inc.
CONTENTS ANSFE D TO: I o Lowell Waste