HomeMy WebLinkAboutSeptic Pumping Slip - 74 SHERWOOD DRIVE 7/21/2016 Commonwealth of assac usotts
r City/Town of a
w i
a System Pumping ocor
Form 4 ( E`, b 'f1Cl'',
DEP has provided this form for use by local Boards of Health, Other form it a gibe usedr Ibuf thevi a
information must be substantially the same as that provided here. Before usi � �� als fib'r niivith our
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms the
computer, use
only the tab key Address _
to move your r tf3vw C _ r
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
4:1 S\J 1(-V\,\(- CA 0\0
Name
Address(if different from locati n)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
avv-
I Date of Pumping Date 2. Quantity Pumped: Gallon's
3, Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle Licen es Number
Company ---- IwlC
7. Location where contents were disposed: Treatment P
_ n
Signature of uler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record-Page 1 of 1
i
Commonwealth of assac usetts
City/Town of
a System Pumping eoor
a
Farm 4
mw
DEP has provided this form for use by local Boards of Health. Other forms may be 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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use (J
only the tab key Address
to move your N " AoA"o�oz d
cursor-do not --use the return City/Town State Zip Code
key. 2. System Owner:
Ix
Name
— C - -- —
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gall— hs — —
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes Eg/No If yes, was it cleaned? ❑ Yes M/ o
5. Condition of System:
6. System Pumped By:
Name V W se Nu
'
�,,,.(�r 1.'G�a:',. -- rep
Companyr � q fp
7. Location where contents w�re disposed: 9��N
blG
Signature auler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record-Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
f �
DATE OF PUMPING QUANTITY PUMPED
CESSPOOL NO IZ YES SEPTIC TANK NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY
COMMENTS:
> f �72
CONTENTS TRANSFERRED TO �w><' J-1 ` � J wZ