HomeMy WebLinkAboutSeptic Pumping Slip - 171 SUMMER STREET 9/9/2015 Commonwealth of Massach6setts �J
City/Town of NORTH ANDOVER. MASSACHUSEW
Pumping System r
Form J AN 06 ?010
DEP has provided this form for use by local Boards of Health. The S I �f dbbbYd ust
be submitted to the local Board of Health or other approving authors I °rl=l
A. Facility Information
Important:
When filling out 1. System Location:
forms on the su..
computer,use i f. .� _ �.. x f v ...
only the tab key Address
to move your ��a, °t`ty „k _ �,. V� a Vk
cursor-do not
use the return City/Town State Zip Cade
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumpingt l 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent. w]""No❑
p � No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: /
t.. . )
�A
Name Vehicle License Number
'f k.G
Comp y
7. Location where contents were disposed;
Signature of ler Date
http://www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record Page 1 of
Commonwealth of Massachusetts
r -
City/Town of NORTH ANDOVER, MASSACHUSETTS
System umpin g Recor
r` Form 4
DEP has provided this form for use by local Boards of Health.t umpm "R 4; ust
th. The System P
be submitted to the local Board of Health or other a roviri author f y
A. Facility Information
Important:
When filling out 1. System Location: 0 r
ri
forms on the .,
l
computer,use 171 SUMMER STREET �'`I 5 �
only the tab key Address
to move your N ANDOVER MA 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
nb LTRA RORRRT i
Name
�nm Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 8/29/06 2. Quantity Pumped: Gallons 1000
Date
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? ® Yes ❑ No
5. Condition of System:
GOOD
6. System Pumped By:
RAGGS SEPTIC SERVICE INC.
Name Vehiole License Number
Company
7. Location where contents were disposed:
GREATER LAWRENCE SANITARY DISTRICT _
9/15/06
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc>06/03 System Pumping Record•Page 1 of 1
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
j
DATE
i
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
1 . 01 I I)o e
DATE OF PUMPING //-/d '-' QUANTITY PUMPED / 00
CESSPOOL NO ZYES SEPTIC TANK NO YES
NATURE OF SERVICE: ROUTINE k l EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY
COMMENTS:
CONTENTS TRANSFERRED TO
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: QUANTITY PUMPED' GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: ��Z���'�'`+��� � �
COMMENTS:
CONTENTS TRANSFERRED TO:
i
NORTH ANDOVER MmechUSGM
cm fl n
7 w
e
LISA ROBERTS 171 SUMMER STREET
u �g�. d: loon gallons.
Date Pumping: a/o7/a7
1: No El Yes , 0 Septic
Tank* te0 0 Yes X
RAGGS SEPTIC SERVICE, INC'
System e:
d .b.a. ® COM AU SEPTIC License
Contents to:
F T HBURG
Inspector AGGS SEPTIC SERVICE, I
Date 10 1