HomeMy WebLinkAboutSeptic Pumping Slip - 31 JAY ROAD 8/30/2017 12" cimgmonvv alth,00 Masscich
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system Pumping Record JAN 2 X10
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DEP.has provided this form for use by local Boards of Healt ,-,Tp1Pmpting Record must
be submitted to the local'Board of Wealth or other approving authority.
k Facility Information
•
,...Important:
When filling out 1 System Location:
forts on the'.
computer,use if .. .t4z
only the tab key Address '
to move your � ' • >;, ,�
cursor-do not Clty/Town State Zip Code
use the return .
key.
2.' System Owner:
i
Name
,an Address(if different from location)
City/Town State � �� � ip, ode
Telephone Number
,
" . Pumping Record f
. 1. Dat&of Pumping Date 2. Quantity Pumped: Gallons
�3ype of system: F1Cesspool(s) ptic Tank ❑ Tight Tank
[)' Other(desoribe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Ye �..
5. Condition of System:'
• 6. Sy em Pumped.By:
fi"c� I
Name �rVehicle License Number
Company
7, Location where contents were disposed:
AjaAld/ mt-q
Signature of Hauler hate
http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
t5fomA doc-06/03 System Pumping Record•Page 1 of 1
OR TH A J0 VE' I ASSACHUSETT'S
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be submitted tded this form"for use by local Boards of Health. Th S stem Puf °°d
o the coca! Board of Health or other approving auth rlty, 1g� ecor must
b r �,ti ifs ia ,m
& Facility Information
t...,
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,;;�,�,-.1fldhen fillhlq pWt, System I.00At10n
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only the tab key Address !
la move yor Cl P1"own �` �C'2 a
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Us,@ the r4tur» tY Stat Zip Code
1�"`"'' '' �1 �}'I /� pry
{'. k8y. y v lSystem Owner,
r ±• � r r i`I 1 ' 'r F t ' V �r `
Hr Name:--
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Address(if differ nt r
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City qwn
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tat® �""" Z1 Code '.
Telephone Number
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Pum 10� a ,�, t,l•
,R. fiord
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1' Date of Pum In - r,
Date d z' Quantity Pumped;
Gallons
31 ,Typs of system. Cesspools Tank
� ) tXeptic ❑ Tight Tank
Other(desoribey;
4 Effluent Tee Fliter'preseW.® Yes, 'No' If yes, was It cleaned? M Yes ❑ Na
,
COflditlon Of Systm;'' 1 M
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htfp; www mass gov/deo/water/ep�prOva)s t$forms,htm#Inspect
t5fomi4.doc+O8103 System Pump4ng Record-Page t of 1
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Commonwealth of Massachusetts
Put 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 Pumping Record must
be submitted to the local Board of Health or other approving autho,t�k"y-_
A. Facility Information
Important: A[T 0 5 2006.
When filling out 1. System Location: r ll I
forms the �/ r �"^dVi i'�Ie�,r V G d „ ➢�
computer,
r, use ( :� �'�
�'..� ..__. .,� ....�'
. ._.� ...._.._ _._. _.__..__..._...—
onl the tab key Addressto / .........__ mm ...... _.
your
cursor�do not -City/Town-/Town
use the return y State Zip Code
key. 2. System Owner:
Name _. ... —_.._..
IX
etavn
Address if different from location)— �k
r _ .
State C d
e
Telephone Number
B. Pumping Record
CC 1";: r
1, Date of Pumping Date .°_ —...--___ 2. Quantity Pumped: . ......
Gallons
3. Type of system: ❑ Cesspool(s)Z21
Septic Tank ❑ Tight Tank
❑ Other(describe): _..._... _......,. _— ,...... —_. ---._w.
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
1)0d;
6. System Pumped By:
Name vehicle License Number
Company
7. Location where contents were disposed:
Signatu of Haul r Date
_.-.
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
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S:YSfiEM PUWIN4 RECORD
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SYSTEM OWNER&ADDRESS SYSTEM LOCATION
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DATE OF PUMPIN .LjQUANFITY'PUMPED
CESSPOOL NO YSS, r SEPTIC TANK NO YES
NATURE OF SERVlCB;'; Q,hlv' p.NE C EMEROENCY
OBSERVATIONS; '
GOOD CONDITION�•',::�:. FULL TO CQVER
4AVY OREASE" .r BAFFLES IN LACE
ROOTS LEACINIELD RUNBACK
EXCPSSNE,SOLIDSPLODDED
SOLM CARRYOVER OTHER,EXPLAIN
SYSTEM PUMPED BY y
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COMMENTS, ,..
CONTENTS TRANSFERRED TO
TO" OF NORTI-1 ANDOVER
r SYSTEM PUMPING RECORD
ti1'5TEM OWNER & ADDRESS SYSTEM LOCATION _Al",", (example: Icf1 iron of house)
L).vTC OF PUMP INC; QUANTITYPUMPEDZ27)(; l, l,ta.� ti
NO YES SEPTIC TANK: NO YES
' -\TUBE OF SERVICE: ROUTINE EMERCENCY
�aIJ. f 17YAT10NS:
G'UOD CONDl1'ION, FULL CUYCI
HEAVY CREASE BAFFLE'S IN I'LACI;
ROOTS LEACHFIELD RUNBACK.,
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOYER PRHFR (E;XPLAM)
y1'y'1`L PUMPCaY:
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TOWN OF NORTH ANDOVER
SYSTEM PUMP RE CORD
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DATE OF PUMPING: � -�/ 112�71-. QUANTITY PUMPED GALLONS
CESSPOOL: NO � YES SEP'T'IC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASEBAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
E XCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
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SYSTEM PUMPING RECORD
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EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER
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