HomeMy WebLinkAboutSeptic Pumping Slip - 69 OAKES DRIVE 5/9/2016 Commonwealth of Massachusetts
„
City/Town of �� �
System uin Record
Form 4 r` "
DEP has provided this form for use by local Boards of Health. Ot the
information must be substantially the same as that provided here A eck 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.
A. Facility Information
1 ys-L sat w-Leerft of hou house, right front of house, left side of house, right side of hou Left
sle, left side of building, right rear of building, under deck.
oax
City/Town State Zip Code
2. System Owner:
- - ----
Name — - ---
Address(if different from location)
— ----- -------
City/Town Stag 1, ip Code
(( `-
Telephone Number
B. Pumping cord ,
1. Date of Pumping Date-- 2. Quantity Pumped: Gallons
3. Type of system: ❑ C spool( ) ®�pt c Tank ❑ Tight Tank
44 ,
ther(describe):
4. Effluent Tee Filter resent? 9–N6`--
- ,.. .
p ❑ Yes ® fVa If yes, was it cleaned? F-1 Yes a-No
5. Condition of Sy to : a
6. System Pumped By:
Neil J. Bateson F5821 _
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Lo tion where contents were disposed:
G.L.S. LoW61 Waste to
Signature if H ler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
N W City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping
w
Firm 4 �
DEP has provided this form for use by local Boards of Health. The System Pumping Recor ust
th rte.
be submitted to the local Board of Health or other approving
A. Facility information
Important:
1 S ste Location:
When filling out � Y
Location-
forms on the �� �' V/P!r),
computer,use -- ; �
only the tab key Address r ` iJ r
to move your
cursor-do not 6tyTrown StEfte Zip ode
use the return
key. 2. Sys em Owner:
---
Nam
man Address if different from location)
City/Town State T-7 / o
Telephone Number
B. Pumping Record,-,
p
1. Date of Pumping 2. Quantity Pumped: c)
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes 0 If yes, was it cleaned? E] Yes ❑ No
5. Condition of System: ///���
6. S tem Pumped lay:
f ,
Vehicle License Number
Company
7. Loca ikon where contents were disposed:
Sign re of ule Date
http://www.mass,gov/dep water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record.Page 1 of 1
fI
L
UAI
SYSTEM UMPTNQ REC;OR .)
3YSTE UWhI R & ADDRESS l -
-�
TSY7TEM L(,c TTC)N 4.rW( ,
� dam.
E,
DATE OF PCIMPINC7._. ,_._. �-
f ._ :r_.. _Q(,IANTITY PUMPED, ) 0. 17
L> SPOOL: N Y
. . Eb 5aptic Tank: NU
NA ruKE OF SERVIC RUU'rIN
ObSERVATIUNS;
,000D CONDITION(",
FULL ,ro COVER .
HEAVY ORFAsE 13Ak�F1 ES IN PI�AC k.
ROOT'S _.
13XC: SIVE SOLIDS W_. FLOODED D RUNBACK
`SLID CA YOVER. ..^. OTHER EXPLAIN
SyrLom Rwnped by
Q._ c .,. /?a 7 . . ,�ra�rz� rrl
CUMMENTB,
L'UN I'EN I'S MANSF'ERUD I'o
{x'1°0 Jq� �p°'y)��,/y�'°6{("�q
r Y . "`N'/� Tom`,p" ' 4m! 1 4w 9 b ',..
.'4'g°7"'EM OWNeR a SYSTEM LOCATION
(example: left front of bouse) ? �
Uri'1" OF PUMPING: QUANTITY PUMPED (;ALLO.' 5
%.i"SSI'UUL: NO YES SEPTIC TANK; NO YES
NATURE OFSERYICE; ROUTIN8 _4LL EMERGENCY
()Iiaf:RY:1T10NSs• s' °
GOOD CONDITIOM FULL TO COVE(t
HEAVY GREASE 13AFFLES° IN J'LA4„ L
ROOTS LEACHF1RL D RUNBAC'K-
CXCESS'I E SOLIDS FLOODED
SOLIDS CARRYOVER �PWHITR (EXPLA.IN)
ua.'l kl r�tTS:
QNTI,,7q'I'S TRANSFCItRE, 0 TO.