HomeMy WebLinkAboutSeptic Pumping Slip - 67 STONECLEAVE ROAD 8/10/2016 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSAGHY_§Ij�,
System Pumping Record NOV 14 Z007
Form 4
DEP has provided this form for use by local Boards of Health. T1W Vu ord must
be submitted to the local Board of Health or other approving a(d ISTHM) I PA M M��
A. Facility information
Important:
When filling out 1, System Location:
forms on the d
computer,use
only the tab key
to move your
cursor-do not State -ZI-P Pode
use the return City/Town
key. 2. stem own
,
Name
Address(if dffferent from location)
------------
City/Town State- Zip Code
Telephone Number
B. Pumping Record
1. '�o 10 Date of Pumping Date [M-1-W-0 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool($) q/Septic Tank F-1 Tight Tank
❑ Other(describe): _ _ _.__-.--_..________----------.------
4. Effluent Tee Filter present? ❑ Yes 19'No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. system Pump
'qd By:
Na Vehicle License Number
Company
7. Location where contents were disposed:
Co LS
Q
Signature of Hauler Date
http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
t5form4,doc•06/03 System Pumping Record-Page 1 of 1
TOWN OF
SYSTEM PUMPING RE CORD
DATE:4:_�-
SYSTEM OWNER & ADD RE SS SYSTEM LOCATION
A. (example:left front of house)
DATE, OF PUMPING: QUANTITY PUMPED : GALLONS
CESSPOOL: NO YES SEPTIC TANK- NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY -
OBSERVATIONS: FULL TO COVER
GOOD CONDITION
HEAVY GREASE
BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
-
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM[PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: Le
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
� �
DATE OF PUMPING: � QUANTITY PUMPED „'GALLONS
CESSPOOL: NO �YF,S.... SEPTIC TANK: NO YES "
NATURE OF SERVICE: ROUTINE �EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROO'T'S LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
i
i
COMMENTS:
CONTENTS TRANSFERRED TO: