HomeMy WebLinkAboutMiscellaneous - Exception (133)TOWN OF NOR I NDv,,,
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SYSTEM PUMPV
DATE RECORD
SYSTEM OWNER &-ADDRESS
(611 leli,
LUCATION
DATE OF PUMKNG,-.__�.';-9_-//_,
—QUANTITY PUMPED:
CESSPOOL: Septic Tank: NO
NATURE OF SERVICE: ROUTINE_
M.ERGENCY
ObShRVATIONS:
GOOD CONDITION /FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS ____ LEACIM-ELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER__ OTHER EXPLAIN
System htmpcd by
2
COMMENTS,
CONTENTS TRANSFERUD TO
a
1�\- Commonwealth of Massachusetts - Ri!!D
City/Town of
System Pumping Record OCT 19 2011
Form 4
M , TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other form HE LTH D P T
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 (Right rear of hou . Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address 07 T^ _ r^��/ _4� S+
City/Town (( �� �(/� State Zip Code
2. System Owner:
Name l
Address (if different from location)
City town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
State Zip Code
:
Telephone umber
Pr(L�-(
Date 2. Quantity Pumped: Gallons
Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
5. Condition f System:���L/ l f"
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locationere contents were disposed:
G.L S. Lowell Waste Water
na
t5form4.doc• 06/03
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
Date
System Pumping Record • Page 1 of 1