HomeMy WebLinkAboutSeptic Pumping Slip - 137 FOREST STREET 4/13/2016 Commonwealth of Massachusetts
City/Town of
a System Pumping cord NORTH
Fora 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this 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:
forms on the
computer,use only the tab key Address ` — ❑— --------— — _----_❑ -- — —...__
c move your �.
cursor-do not City/Tow—n�? State Zip Code
use the return
key. 2. System Owner:
Name �� a,.��� 1❑ —
I a
Address(if different from location) r;r N F
City/Town State Zip Code
-roe p hone Number
` wa° C❑
B. Pumping ecord
1. Date of Pumping Date — 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 41?"-Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes No 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: I.
Ipswich. MA.
Signature of Hauler w � „ Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System PLimping Record NORTH ANDOVER
Farm 4
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the
information must be substantially the same as that provided here•Before using this form check with y w
local Board of Health to determine the form they use.The System Pumping Record bs,
the local Board of Health or other approving authority within 14 days from the pumpl�g date�n �� r /
accordance with 310 CMR 15.354.
f 11
/jii G
A. Facility information Y
l C
Important: k r tW k l r i; I ti,)f (i 4 AJ1x)\J,f
When filling out 1, System Location:
7 y/ �a Ii1 faV ifi(1i i��i fl�'r PJl
terms me 1._, r,r ✓ - _, _. �, ,> ,,z
computer,use r"'
only the No key Address
,� r - ,
to move you+ .--✓'!-� ,r.. d'G!"�^'�" — Stale Zip Gods
cursor•do not cltyrrown
use the return
key 2. System owner:
Nana
�,. Address(If ditferent from location)
zip c -
__ ofie ...
citylTOVm
Telephone
B. nlTltl g Record
2 Quantity Pumped. Gallons �
1. Date of Pumping ate
3. Type of system' ❑ Cesspool(%) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): —
4 Effluent'Tee Filter present? ❑ Yes ❑ No It yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System-
6, System Pumped By.
Name Veri1Ga License Number
Company S.
7. Location where contents were disposed; A
Slgnaluia at Hauler Date
Signatulc of Recelxiug Fadility pate
System Pumping Retold•page 1 of 1
15rorrM.dac 03146
- Commonwealth of Massachusetts
own of T ANDOVER R MA SAS. v
� City/
-- System Pumping Record
Form 4
rv.
DEP has provided this form for use by local Boards of Health, T , f p ��f
t�`4�� fry � d must
be submitted to the local Board of Health or other approving autl brl 1 u d r
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use l _ t c,-L5 A–
only the tab key Addr ss
to move your
cursor-do not
use the return cityaowff State Zip Code
key. 2. System Owner:
1C)o Cam,
Name — —
Address(if different from location)
City/Town Statef Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping .2 pate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sy tem:
-- � --
6. System Pumped By:
"_))i (Uf ' _ ( -
Na e Vehicle License Number
Company
7. Location where contents were disposed:
G. w . -- —Lawronce,n ,
Signature of Hauler Date
http://www,mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.daa 06/03 System Pumping Record•Page 1 of 1
�
Commonwealth 00fassac
City/Town of
� di
System Pumping Rec—
/
Form 4
�
DEP has provided this form for use by local Boards of Health. Other forms may be used. but the
information must be substantially the same asthat provided here. Before using this 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 nr other approving authority within 14 days from the pumping date in
accordance with 310 CN1R 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use
only the tab key Address
to move your No,-Av) |
cursor'donot
use\homtu,n ty[/own State Zip Code
key.
2. system {) |
Name .
Min Address(if different from location)
Qty/Town state Zip Code
Telephone Number
B. Pumping Record
(J��
1. Date of Pumping Date - — - 2� Ouon�v Pumped� Gallons
3. Type ofsystem: El Cesspool(s) [2"'SepticTonk El Tight Tank Fl Grease Trap
�l
Other(describe): .
4. Effluent Tee Filter present? F1 Yea 9No |f yes, was itcleaned? E] Yee [:1 No
5. Condition of System:
G. System P mp dB :
Name Vehicle License Number
Company
7. Location where contents were disposed:
~
Signature vfHav|e6 '— '` Dam
(
Ipswich, MAI 101 �
\
Signature cd Receiving Facility Date �
t5fonn4doo'0306" System Pumping Record'Page 1 of