HomeMy WebLinkAboutSeptic Pumping Slip - 41 NORTH CROSS ROAD 5/24/2016 L
Commonwealth of Massachusetts
City/Town of NORTH ANDOVE ACHUSETTS
System Pumping Record
Form 4
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DEP has provided this form for use by local Boards of Health. T ". keco d must
be submitted to the local Board of Health or other approving aut
t
A. Facility Information
Important:
When filling out 1 System Location: E4111 DE-AR MEN1
..........
forms on the
computer,use
only the tab key Address
to move your
cursor-do not A,,o
use the return City/Town state Zip Code
key. 2. SyVem Owner:
P�A
Name
Address(if different from location)
City/Town State Zip Code
Pmm
Telephone Number
B. Pumping Record
s
Date Gallon
0 0
1. Date of Pumping -L-01z 7 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) VSeptic Tank El Tight Tank
❑ Other(describe): ------
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? [--j Yes ❑ No
5. Condition of System:
6. System Pumpe By:
jr
Na 'e
(I Vehicle License Number
Company
7. Location where contents were disposed:
Signature', f Hauler Date
http://www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of I
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
' (example: left front of house)
DATE OF PUMPING: �,QUANTITY PUMPED GALLONS
K
CESSPOOL: NO YES SE TIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY,
COMMENTS:
CONTENTS TRANSFERRED TO: