HomeMy WebLinkAboutSeptic Pumping Slip - 1491 TURNPIKE STREET 5/24/2016 Commonwealth Of Massachusetts
u
City/Town Of
System Pumping Record
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may ie 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.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left ht side of whau , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ' " 11 0
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Statq_, 7ip Code
s ss
Telephone Number
B. Pumping Record
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1. Date of Pumping 2. Quantity Pumped:
Date .. 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 Mystem: I
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati v here contents were disposed:
Lowell Waste Water
f
r
Sign toe Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
- City/Town of
System Pumping � n
4/
Form 4 A IlC
DEP has provided this form for use by local Boards of Health. Other f rMs' may k� s,68,u ��th6
information must be substantially the same as that provided here. Be�ore`ia6ing�th s forrrf;-c`Te'e nth 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
When filling out 1. System Location:
forms on the
computer, use _ab
to movet oukey Address .,.._ C. - --m ,__
, "_, ..
cursor-do not State use the return Zi
City/Trnnm — - p Code
-
key. 2. System Owner:
Val Name -
Address(if different from Nation)
City/Town State _ Zip Code
Telephone Number
B. Pumping c r
1. Date of Pumping .2. Quantity Pumped: Gallons --
3. Type of system: ❑ Cesspool(s) optic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ o If yes, was it cleaned? ❑ Yes ❑ No
5. Condi 'an of S stem: 7 _
6. Syste Pum�aed By-
w
-------- - -
Name - Vehicle License Number
Company — -
7. Location w re ontent ere sed:
Alr..
;,7 —
Sign re H uler Date
t5form4.doc^06/03 System Pumping Record>Page 1 of 1
TOWN OF ANDOVER
SEPTIC SYSTEM SERVICING
REPORT
Date:
Homeowner:
Pumper
Street A Address.,z
Phone Phone
Nature of S-arvice: Routine
Emergency
Observations: Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other (Explain)
Description of Work:
Comments :