Loading...
HomeMy WebLinkAboutSeptic Pumping Slip - 557 BOXFORD STREET 10/13/2015 ,f Commonwealth of Massachusetts City/Town of yitem u in a�cord U'.. r " 2U14 .�` Form 4 � H PiAI> 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/ #front of hous Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right ran of building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner: Name Address(if different from location) CitylTown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: ��.-- Date Gallons _z 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: Vl\,- 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. Locatii� re contents were disposed: 034L S Lowell Waste Water Sign t e Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I i Commonwealth of Massachusetts HE u City/Town of I 1 t System Pumping Record Form 4 ]V�R a wcw Nc T D DEP has provided this form'for use by local Boards of Health. Oth e 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:CRi Kt front of hous eft/Right rear of house, 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 State Zip Code 2. System Owner: Name Address(if different from location) City/Town State ode �7 Telephone Number B. Pumping Record 4—�) � 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) D-"S`epticTank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ©' o If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio here contents were disposed: G- L S-,Q Lowell Waste Water ^� Sign to a Haule Date t5form4.doc•06/03 System Pumping Record-Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECD DATE: SYSTL.' WNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE 'UMPING: QUANTITY PUMPED C GALLONS CESSI',:_ NO YES SEPTIC TANK: NO YES NATUI'. ')F SERVICE: ROUTINE t-/ EMERGENCY OBSE 'IONS: JD CONDITION FULL TO COVER IVY GREASE BAFFLES IN PLACE OTS LEACHFIELD RUNBACK ESSIVE SOLIDS FLOODED .IDS CARRYOVER OTHER (EXPLAIN) SYST. J ,IPED BY: COMI 'S: CON' ' TRANSFERRED TO: