HomeMy WebLinkAboutSeptic Pumping Slip - 206 FOREST STREET 4/14/2016 < uu G ri t h of ass hU
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cityrrown of NO. ANDOVER
System Pumping Record
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DEP has provided this forum for rise by local Boards of Health, Other forms ntsy be used, but the
inform ation must he substantivally the same as that provided here, Before rlsirag this for-rra, check with your
local Board of Health to determine the farm they rase. The System Purrtping Record rnust be Submitted to
the local Board of Health or-other app OVing aukharity withirr 14 days from the pun'iping date in
accordance with 310 CMR 15.351.
A. Facility Information
When filling out 1. System Location:
forms on the
Computer'use 2,06 FOREST° t':~T.
only the tab key Address
to move your HO, ANDOVER IAA 01845
cursor-do not - --
use the return Cityf own State Zip Code
key, ? Systern Owner:
C)C:>UG BEACH
__-..... ................-----
Name
nun Address(if different from location)
- -- ---- _. - --------------— -- —— _ -_.
Cit y fl-own Mate Zip Code
_ - _ ----------
Telephone Number
B. Pumping Record
Oa 1 C)U
'1. Date of PLllflping _ 2. C�uantity PUrnped: _._.. - ._.. ----__
)arc; Caallora.�
3. 'Type of system: WW1 Cesspool(s) Ceptic'Tnnlc E_1 "right Tank Ej Grease Trap
Other(describe): -- _ - _- .....
4. Effluent'Tae Filter present? Yes No If yes, was it cleaned? 0 Yes No
. Condition of Systen-i:
6. System Pumped Icy:
JAMES H. CURRIER F179 406
-- --.._.--- — - -_ —-. _. _._
Name Vehicle License Number
J's CtWP I G & DRAIN
Company
7. Location where contents were disposed:
GE.SD r
Signature of Hauler gate
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping record>Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: _(i
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
4
V- Jd
DATE OF PUMPING: [�� '� " U� 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 LEACIF,IELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY;
COMMENTS:
CONTENTS TRANSFERRED TO: