HomeMy WebLinkAbout2008, 2004, 2000 - Septic Pumping Slip - 103 TUCKER FARM ROAD 9/11/2019 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSE
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of H Lh.oeThe_System Pumping Record must
be submitted to the local Board of Health or other appro ingD
A. Facility information JUL 0 7 2008
Important:
When filling out 1• System Location: TOWN OF NORTH ANDOVER
forms on the ; "'S;C P E` r,. d7 HEALTH DEPARTMENT
computer,use if(, l.-IL �'
only the tab key Address f� r
to move your hr ') t cfy"C-
cursor-do not City/Town State Zip Code
use the return
key. 2• System Owner:
e 6
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping � � � '� 2. Quantity Pumped: C
Date Gallons
3. Type of system: ❑ Cesspool(s) U�Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Sy,Item Pumped By:
e Vehicle License Number
Company
7. Location where contents were disposed:
FN
ra:
ra
Sig'rr&ure o• auler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
RECEIVED
. OF NORTH ANDOVE . OCT 0 5 2004
S g M PUM
UAl P1NO RECORI.t
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYS EM OWNER & ADDRESS _ i_OCA I-ION
SYSTEM
/ot3 7� r _ ..
moo.
DATF. OF PLIMPIN(7
_._._...._. ... -.. ..�...._._. _QL)ANTTTY PUMPED:...
C LSSK)OL: NO-- YES,. / Sapuc Tank: NU_ YES "
NA ruRb OF SERVICE: KUU'CI.NE ►/ laMEiRCII NC'Y
UbSERVATiUNb;
GOOD CONDITION FULL 'i'U COVER
.HEAVY OREASE BAFFLES IN PLAC:L.
ROOTS
_..._. LE.ACHFIELD RUNBACK
EXCESSIVE SOLIDS _ _ FLOODED
STOLID CARRYOVER ^ OTHER EXPLAIN
Syst4om pumped by
Alt.
LA)MMENTS
CON I EN I'S f'KANSt'6Kp,6D 10
it
A/,6 AVZ)6ver 4. SMART'S sEPrac TANK $SCE
)J,b "",O,n r+. 47 RAILPDM STVjMr
A/e rh A thaw:,, BPAM7M, MA 01835
W®.v -aab 4 978--372-7471
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