HomeMy WebLinkAboutSeptic Pumping Slip - 178 GRANVILLE LANE 6/10/2016 Common wealth of Massachusetts
North Andover, Massachusetts
�"ystem I'urrraairr�Recor^rl
System Owner& Address:
Marc Bourassa (j
178 Grandville Lane
North Andover, MA 01845 . E u i r
Location of system: Front
Date of Pumping: September 4, 2012
Type of system: Septic Tank
Gallons Pumped: 1500 gallons
System numt)ed by:
Service Pumping& Drain Co.,Inc.
5 Hallberg Park
North Reading, Ma
License#: BHP-2011-0413,0412,0411,0410,0409,0408
Contents transferred to: Greater Lawrence Sanitary District
Clete: September 4, 2012 Pumping Technician: AS
This is PROPRIETARY and CONFIDENTIAL information that may
be used only by the Board of Health for regulatory purposes
Commonwealth of MassachillAsetts
Ni-
City/Town of
- System Pumping
?
Form 4 )� C 2 d� �Vh�
DEP has provided this form for use by local Boards of Health. Other for s,m�ay..,66.used, but the . r
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
Important:
When filling out 1. System Location:
forms on the
computer,
------------
Y tab k e y Address
to move
,e
use
cursor d not City/Town k ` a - V - State� "
Zip Code
key. 2. System Owner:
reb
Name
------- -----
----- ---------
------- -- - ----- -
snra Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping cord
ba#e Callan ° ".
mping � 2. Quantity Pumped:
1. Date of Pu s
3. Type of system: ❑ Cesspool(s) -8'6ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ®" No If yes, was it cleaned? ❑ Yes ® No
5. Condition of System:
6. System Pumped By:
a
ame Vehicle License Number
7
Company
7. Loc�aion where contents were disposed:
a�
i nature of V~I -
Sig auler m Date
t5form4.doc^06/03 System Pumping Record p Page 1 of 1
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OF NO. t HX�NDOVEP, t
_. Y T A�i P uMF'11?1C REC'OR1.) � ,/ �OF'
. .. . . , m,
5YST1~ivl OWNER AI70RESS SYSTEM LCICATTC)N
DATE OF PlUPIAI(3: . ' ",u. _ .-pl,IANTITY PUIv4PED k i!11
4.C0SPC)OL: NO_ ,,,. YES,. SOPtic Tank: NC)
NA FURS OF SERVICE: ROU'f1N>~ 4° EMEROENC
ObSF,RVATIONS: r
GOOD CONDITION � �4FuL.L COVER
HEAVY OREASE BAFFLES IN PLAt'.L•,
ROOTS _ LEACMFIELD RUNBACK
EXC USIVE SOLIDS FLOODED
SOLID CA Yo VER OTHER EXPLAIN
SYrLvrn Pumped by
i
�,'uMMNNTS.
L'VN PEN'I'S I'KANSFbKnD I'()
TOWN 0F NO R'Fl—1 ANT
SYSTEM P UN'T I'l N G
lo
HM OWNER & ,ADDRESS S Y ST E N/I L 0 c
OF P U N/l 11 N C -L(-,L,LL)' -'Y P J M P
Q IJ A N'TT[ D
-"T'l CTA N K 0
U 0 L C) L YES S I"I
0 URE OF SERVICE: ROUTINE E M E'R G E N C Y
F'RY :\TIONS!
GOOD CONDITION I,'ULL TO COVE
H 1A V Y CREASE 13 A F F I-ES IN 1)L-,�C',F
R 0 0 T S LEACHFIELD
LXCESSiVE SOLIDS FLOODED
SOLIDS' CARRYOVER O�H F R (EXPLAIN )
FLATS:
T! A IN S I' E I Z I ED TO
FORM 4- SYSTEM PUMPING RECORD
Commonwealth of Massachusetts
Massachusetts
S
ystem Pumping Record
ystem 0-1w—ner System Location
/V
'9
Type: Emergency ❑ Routine,, El"'
Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes 12/
Date of Pumping: Quantity Pumped: gallons
System Pumped by (Company): F"(")/ACZC Permit #:
Contents transferred to:
Contents disposed at:
Date ? Pumper Signature �7
Condition of system/other commenis:
DEP APPROVED FORM-12/07/95