HomeMy WebLinkAboutSeptic Pumping Slip - 171 FOREST STREET 4/13/2016 Commonwealth of Massachusetts f "
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City/Town of
JIJI'!
S System Pumping Record
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information must be substantially a same a that provided here. Before .
p Y s may be used, but the
using this form, check with your
local ward of Health to determine the farm they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out
y Location:
f ours on the Stem ...Q c M1 .,,1.. .... :'.:. 1 .� ..,r
only the tab key Address .-..-. �_.. 4 ,
- ..... .. _, „,
to move your _
cursor �i do not City/Town State p Code
use the return
key. 2. System Owner:
VQ Name
r Address(if different from location)
City/Town
– State— 1 �..� Zip Code
Telephone Number
B. Pumping r
ping _.... .........M� w.�_�.,j tY Pumped: - �
'I. Date of Pum Date Gal Quanti
3. Type of system: ® Cesspool(s) E1-§e'pti
c`
Tank E] Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes If yes, was it cleaned? [j Yes ® No
5. Condition of System:
6. Syste Pump@d By:
Vehicle License �
Name icense Number
Company
contents per s used:
J 7(o:
here Conte p
7. Locat�t w/aulerrC--�'Sig ure
t5form4.doc^06/03 System Pumping Record 4 Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM J
DATE
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPIN04'— j° )eLA 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 LEACLIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
1 '
CONTENTS TRANSFERRED TO: