HomeMy WebLinkAboutMiscellaneous - 204 MILL ROAD 4/30/2018 (3)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
APR 24 2012
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 Locati�Le Right front of house, Left / Righ a of h Left / right side of house, Left /
Right side of buildin , Left / Right front of building, Left / Right rear of building, Under deck
9 9 9 9 9,
Address
Cityrrown
2. System Owner.
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
State . Zip Code
5tatet� � � l � / Zip Code
Telephone Number CL,`J�
�--c 9
Date2. Quantity Pumped
Cesspool(s) Q e�/ptic Tank
�oc-,
Gallons
❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes El"No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S. Lowell Waste Water
i
0:l ,
F5821
Vehicle License Number
Lf—'--�a
Date
t5form4.doc• 06103 System Pumping Record • Page 1 of 1
TOWN OF 1 " "Ui/r
SYSTEM PUMPING RECORD
DATE: a- 1,6 -4'
SYSTEM OWNER & ADDRESS
V" l q
(D C) Lf �)
U
pu—
DATE OF PUMPING:
RECEIVED
FEB 2 3 2005
TO
HEALTH �DEPAF2TM NT�R
SYSTEM LOCATION
(example: left front of house)
C -80"c C)
t�6e-
_ rFk
b --O QUANTITY PUMPED
CESSPOOL: NO L, YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
coNTENTs TRANsFERRED To: G.L.S.D Lowell Waste
GALLONS
i