HomeMy WebLinkAboutSeptic Pumping Slip - 1020 SALEM STREET 12/9/2015 I
Commonwealth of Massachusetts
City/Town Of
System Pumping Record „� , °?,WI
�.. Form 4 MWI�m CL o��u��RI'11111 NDOV ��
HEALTH DE',1ART
DEP has provided this form for use by local Boards of Health. Other o'°r°r 's fna b'e uffie '; of Je
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 house, Left ri ht sltl_ f hod e? Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address CJ
City/Town State Zip Code
2. System Owner: j
Name
Address(if different from location)
City/Town Stat Zi ode
Y C p
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? --'
p El Yes 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,L here contents were disposed:
G.L S. Lowell Waste Water
Sign to`e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
its monw alth Of Massachusetts
Aty/Town of
System Pumping Record 1
Form 4•
I
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
nt:
,sing out 1. System Location: „
n the
er,use:tab key Address ) C
your �l° " ° at
•do not CitylTowm State Zip Code
return
2. System Owner:
Name
Address(if different from location)
City/Town State _ Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: P
5
r
1
6. System um ed,By:
Name . Vehicle License Number
Company
7. Location e e onten we isposed:
LJ '
Signatu of au Date
m4.doc^06/03 System Pumping Record•Page 1 of 1
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
�;—,-4 S-
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
pla 6JAO" -�S
to ,
DATE OF PUMPING: UANT ITY 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 LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: ,VN- re-11-41
CJ
COMMENTS: k°
G
CONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: d 6
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
o,)-0 �a.1-eW-
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:
COMMENTS:
CONTENTS TRANSFERRED TO: .