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HomeMy WebLinkAboutSeptic Pumping Slip - 50 SHERWOOD DRIVE 7/21/2016 J, bl � tT Psi �Y Do A S �J �. Tffq� "R�c`Qrd AS � P has Provided 1r71a loan P.7r �� U - ,arC: Cl r,pd�ln pr Clhoi ® "� SyS;�Tr p -1.�.. ,a ap/7'rinQ aulnorlCy. A, Facility Infarrr)�tlon H"."y '.",p ld^1.A y A,;^f 9 1 J �...� � �� fit •�(:Ju',a'LX,�°.,� )�"" ., ���J��../ Syslam Own Qr rr,� ( r J , (IldVfpPpnl ram iota Ucn CG7nPn. vA o ' __ TolOpnono 1-771 � - m I (� A " Pu g d or n e 1. Cah o! Pumping 2 3. ,Type pl ay)lem; 0 C©9spool( ) 50POC Tan, Q'�0!he�r (descrtbej� ��. ; 4 Effluent Yee Flf(e(P Y09 It _ pp r'.�i y69, n'69 4. C 68ne0? Yes .•rya�'Ii�,,.Si�.'til �f�',�1� li` . tP/ d�� Coridl�Jon�Ql3Xl�Qm � ,.. 'All v .. (' •1 cur v� �,ir. i,�' �/�' ----- t i\ SY �( P�'mped 6y , ! n!, 50in ✓4� ))r �aU wham Corjlenl ywo disposed: 7 t , r 9 I r ^�;,-'�^rrww,mass,gov/dapJwaler/approvaJs/lblorms.n�mal�sn©c' ✓Y" M Commonwealth of Massachusetts � . �. �x ity/Town Of I System Pumping Record X-" �� 1 fll)I Form 4 l DEP has provided this form for use by local Boards of Health. 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 the computer,use only the tab key Address to cu sor move not City/Town — �'. use the-return State Zip Code .key. 2. System Owner: Name --- - - -- Address(if different from location) — -- -- — ity/Town State Zip Code Telephone Number . Pumping ecord 1. Date of Pumping Gate - - - 2. Quantity Pumped: ----- Gallons 3. Type of system: ❑ Cesspool(s) ❑'"Septic Tank ❑ Tight Tank ❑ Other(describe): --- ---— ------------ -- -- -- - — 4. Effluent Tee Filter present? ❑ Yes Q'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition�.. G �, _ A �.. ...� of System, 6. Syste Pumped By r– Name _ _ — --- ---- ---------=----------- "~ Vehicle License Number Company ... ------- -- -- ---- ..oca Ignw er e contents ire disposed: ' Sign tur fif aver --- Date -- — — h.ttp://www.mass.gov/dep/wate approvak/t5forms.htm#inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1 M f , TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER ADDRESS SYSTEM LOCATION (example: loft front of house) n �4,., 1. .0.� l �� �, ,�„A'-"w!.. ry .. t�P F µr;A^","b. /'.......✓ry..) 1. t�r.,�4.,....� \F`H , ', tie •,....,i. „,,. . .. .h' , I DATE OF PUMPING.- QUANTITY PUMPED I< .,..� .GALLONS CESSPOOL; NO - YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE - EMERGENCY OBSERVATIONS, GOOD CONDITION FULL TO COVED HEAVY ASE •RAI+,ELES IN PLACE ROOTS LEACHFIELIIRUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) ti SYSTEM PUMPED RYA , ,r CONTENTS TRANSFERRED T O: � � m