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HomeMy WebLinkAboutSeptic Pumping Slip - 326 FOSTER STREET 6/23/2016 Commonwealth ®f Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record,. Form 4 DEP has provided this form for use by local Boards of Health, The System Pump`ng Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When tilling out 1. System Location: , forms on the � � _ , computer,use only the tab key Address to move your `_1 _ cursor•do not Cltyrrown State Zip Code use the return key, _ 2. System Owner Name aar Address(If different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1, Date of Pumping Date 2. Quantity Pumped: 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 of System; 6. System Pumped By; a Vehicle License Number Company 7. Location w re contents were disposed: go ryN Signs"of Hauler Date http:/twww,mass.gov/depMater/approvalsA5forms.htm#lnspect t5form4.doa 06103 System Pumping Record-Page i of 1 S ��r.\/:{.KS),,Syy(1p(1a�4�"4 5,rr4iti r y7 I r G/ .'1e r `,i!S �r.l,�l Jm✓ , .Yf1Y,1 � ••r7 r y' � �'�' 1,'" 0 u 11 '/"qqy. ` J''',�.,1,. ',�'r r I fd'•fl":!,, .I'r",,^�il ,l.l"tiii f4,y�rw)}�.I,�'�r�'Y,+Y1111:174J'•,�,, ' ,V;!' "� + f ®.local'6oardof Heait 'or ' has pro" Ided I� form for use b lo 61 � � be subml ed tea rother � The�System Pumping Record �r approving autho ity, A Facility Info "m Ion `c Y am Nang out TO N fo`r�rtia on.4hv' 4RT NA k4 T, I J I i�l I .'cornPular,uie (;4*the tab key Address to moor _M v your r � ' .cursor do not, C � � � , M. • tha"npkum •�. ;r, 4/'(own SJ't^,411 t+,:,+;!;,,';7�'': ,,,.':;.,(�,,�)li''n,;Y 'i'., .'.F: .. .., PCodv. IG � ta.r,.c � I t �r�� teil'1 C�W'�'�y WI;''., `� � � rr • a ,"�;rr. ,I''$�+>'''7.:;; , Sys nan,; rG ,�; ,+''�}i' %r7,vl 7f« iJ YI rJr,l �r�4� •I, �n'I. rV a r r a" �:rf° eQ!t Addro""Of dlffer®nt from locallon) Tolephone Number — 1 p Ord ,hum r1? •�. � ; { , „ r, r• t tl t a+��✓i1l it4+4`fr(i l/1(It,r J71�1�'�I'1rrl.l`� ! r. ,u /211 Date 2, Quantity Pumped; } �' Gallona 1"yP.9 Pf system, Casspool(s) Septic Tank ® Tight Tank . �,,, (Other(dascribej ' r• 'r 'y 7� Y,7:ir": '� " '�t,n{}�!'w tai}.�..:.IJ' . ' 4 �f�uen�TaetFlita '��r • Yes NO if yes, Was It cleaned? ❑ Yes ❑ No ' y{ •/r r ri„ .,h,l,.vrGf �7 %'li,a,fvrljl(v,C , / , ./y r��1 ' ' '1r I %r•(�`'1, r�,{+Ylf�l:00'dItJ©n14if WY m+l y 1 .. 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System Location: Ow1'4 Oi I I� iw�l ii. '�T . ��,.. hitL.,t 7i t t��i "I L,. ... forms on the � - � /" �� computer, use W �w on the tab key Address —— — — to move your use the do ot City/Town --� key. 2. System Owner: Zip Cade Narne ---- — — C ' J s". p"`" Address(if different from location) — --- ---- —— -- Yip ,. -- ------- Skate — ode Telephone Number — �wM B. h Urnping Flecord 1. Date of Pumping 2. Quantit Y Pumped: Mons --- ,,,,m,, . Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe); -- ------------------- 4. Effluent Tee Filter present? ❑ Y ( Jo If yes, was it cleaned? F-1 Yes ❑ No . Condition of System: 6. System Pumped B Y p Y Vehicle Licensee .r.r Name Number — — -- w Company 7. ..Locationg where contents were disposed.- � ') � , — --- �% K^ .. n r ,A g ature of rj uler ------- -- Si '_—Date -- http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.docc 06103 System Pumping Record-Page 1 of 1 TOWN OF NORTH ANDOVEk DA i•a � SYSTEM PUM!'ll' Q RECCRL) SYSTEM OWNER ADD SS SYSTEM LOCATION /-7� 1 DATE OF PU Nq; ? _QIJANTITY PUMPED: L:0 SPOOL: S00c Tank: NU, YES... NA rVRE OF SERVICE. RounNE_ _ EMERo hNC•1 1 UbSFRVATIONS; , `�� � ¢;105 COND"rtUN .., Fu LL TO . ovER NAVY � B EAFFLBS I P�A C[,K �. „ LEACKRErLD RLfNEIACK u f rt EXCUSIVE SOLIDS FLOODED „ SOL10 CAKRYOYI8R......._ OrKER EXPLAIN �y®�►m PurrtFred by Ls VUMMhNTS, L uN 1 !~N I S rKANSp•ERjtD I'o TOYM OF NORTH ANDOVER SYSTEM PUMPING R.ECOR-D e ti �'STEM OWNER & ADDRESS � SYSTEM LOC'ATION__ T � --, (czample: icfl from of hou�e) 14VI 'Al U:\Tc OF PUMPINC: "" QUANTITY PUMPCD C,`/\ LL()� ti 1100L: N0 -, "°" 'YES SEPTIC TANK: NO YES ' � ATURE OF SERVICE, ROUTINE EMERCENCY C(ZYAT10NS; COOD CONDITION. d���"� ° F'ULL TO COVEk HFAYY CREASE BAFFLES IN PLACE FOOTS LEACHFIELD RUNBACK., EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER p, HE'R (EXPLAIN) i >v 'I,Lm PUMP CIJ 0Y. hUNINIFNTS: r 0 N I'l:'.N'i'J' !'ItANSFEI IZED TO: TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: � .m.. �� � 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 LEACRFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVE R OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENT'S: r CONTENTS TRANSFERRED TO: