HomeMy WebLinkAboutSeptic Pumping Slip - 1160 SALEM STREET 12/9/2015 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACH, -51-EITT
System Pumping Record
t Form 4 ., f., 2,()0
provided this form for use b local Boards of Health. Th rpp; a R crrC must
DEP has
p YY ' a. ,t @ , �'
be submitted to the local Board of Health or other approving auth rity�.'j)i i i. ;
i
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Addres p'
to move your ���C. �.J/iJ l,/d
cursor-do not City/Town State Zip Code
use the return
key, 2. System O ner:
Name
,ekm Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. [late of Pumping `�t 1 � 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) jSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes K01 If yes,was it cleaned? ❑ Yes ❑ No
5. Condition noof ystem:
6. Syste Pumped By:
> AJ
Name vehicle License Number
company
7. Location where cont is w disposed:
Aq
Signature of Haule Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF
SYSTEM PUMPING RECORD
DATE: -7-2,
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
L -e F-ro ILI
DATE OF PUMPING: fy 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 CARRYOVE R OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENT S:
CONTENTS TRANSFERRED TO: G.L.S.13-2, Lowell Waste
w
TOWN OF
SYSTEM PUMPING RECORD
E:
NDOVER
SYSTEM OWNER & ADDRESS SYSTEM LOCA I ION
(example: left front of house)
DATE OF PUMPING: _ QUANTITY PUMPED : ��� GALLONS
f
r°"l
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: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
i
f
�1'S FM OWNER & ADDRESS SYSTEM LOCATION
(example; left front of house)
UATc OF PUMPINC; 00 a QUANTITY PUMPED e) GALLO'�.'
C.�I:SS1 00L: NO "YES SEPTIC TANK; NO YES I
''ATURE OF SERVICE: ROUTINE Lam' EMERGENCY
O(I.>FRV;\TIONS;
GOOD CONDITION FULL TO COVER
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER YAHER (EXPLAIN) I
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