HomeMy WebLinkAboutMiscellaneous - 150 SALEM STREET 4/30/2018 (4) C
i
� --
� �
'�
{
i
J
I�
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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.
A. Facility Information
1. System Location: Left/Right front of house, Left/Bight Gea , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town staff
Trp Code
2. System Owner.
Name
Address(if different from location)
CitylTown State � �7rCode
Telephone Number
B. Pumping Record _ C
1. Date of Pumping Date 2. Quantity-Pumped: Gallons
3. Type of system:. ❑ Cesspool(s) 2rSeptic 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. RECEIVII
Neil.Bateson F5821
Name Vehicle License Number DEC 0 9 Z013
Bateson Enterprises muses IncCompany TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
7. 7Locaflo ere contents were disposed:
. S.
Lowell Waste Water
Sign JpHaulVe Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
<C�x Commonwealth.of Massachusetts
City/Town of I RIS ®
System Pumping Record
Form 4 JUN 1 2 2007
DEP has provided this form for use by local Boards of Health. T trrl�9�i�i �1e1 rd must
be submitted to the:local Board of Health or other approving aut ACTH cE_ �,� v,�iv
A. Facility Information
Important:
When ruing out 1. System Location:
forms the
computer,use y
only the tab key Address
to move your
cursor-do not
use the:retum CityJTown State Zip Code
.key.
2. System Owner:
CL
Name
iml Address(if different from location)
Cdyrrown State Zip Code
Telephone Number
B. Pumping Record
1. .Date.of Pumping
Date Quantity Pumped:
Gallons
I Type of system: ❑ Cesspool(s) Septic Tank- ❑ Tight.Tank
❑ Other(describe):
4: Effluent Tee Filter present? ❑ Yes B 0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
to-,tjAV�_ �
6. System PupeBy
Name
Vehicle License Number
Company
7.
Loc.at he a conte we isposed:
Sign ure f auler Date
http://www.mass.gov/dep/`water/approvals/t5forms.htm#inspect
t5form4.doc•06103
System Pumping Record•Page 1 of 1
