HomeMy WebLinkAboutSeptic Pumping Slip - 37 WHITE BIRCH LANE 12/15/2015 i
Commonwealth of Massachusetts
City/Town of No Andover °
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other for IPo � � ,
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Inform t' \N 1 1 ► P
Important:When
filling out forms 1. Syste tlon: J '
on the computer,
use only the tab _ �'GS I n/
key to move your Address
cursor-do not No Andover Ma 01845
use the return City/Town State Zip Code
key.
2. System Owner:
Name
ienen
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record _
1. Date of Pumping 2. Quantity Pumped: -
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
i
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. em�Pjmped
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where/potrte is were disposed:
S_teWarfs Pr -treatme t Pra t, 20 So. Mill Bradford, Ma 01835
'"'Signature of Hau r Date
Signature of Re(6 ing Facifity Date
............
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER ACHUSE�TS
MASS
System Pum ping Record
DEP has provided this form for use by local Boards of Health. The System Pumping Record be submitted to the local Board of Health or other approving authority.
must
A. Facility Information
Important: |
When filling out 1. System Location: |
forms on the
computer, use �
only the tab key ~ Address 7—
to move your
oursur-gnnct
use the return City/Town . 8tom Zip Code
—'. 2 System Owner: ~
Name
MAY .1, 1, 2006 St Zip Code
KMN OF K)N Telephone Number
- . _—^--'g . .e~~~..~
1. Date ofPum ing
Dat 2� C)u�n�vPWnOo���
Gallons_
3. Type ofsystem: El Fl Septic Tank El Tight Tank
L1 Other(describe): �
4. Effluent Tee Filter present? 0Yes F] No |f yes, was it cleaned? F-1 Yes El No
5. Condition of :
8 System Pumped
Name Vehicle^~~"=.,u=
,::5 . �
°
/
7. Location where contents were disposed: /Date
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System Pumping Record`Page 1 of
I
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
f
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example; left front of house)
r
DATE OF PUMPING g `0 QUANTITY PUMPED * GALLONS
CESSPOOL; NO YES SEPTIC TANK; NO YES
A—
NATURE_ OF SERVICE; ROUTINE EMERGENCY
OBSERVATIONS:
FOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS P LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED �f
SOLIDS CARRYOVER OTHER(EXPLAIN).
SYSTEM
+m txa} Sjti r ,r�r *'r I .1
I -1
J it i wmn r.nnmr
{
�I q y yl)dr jt1 1
Q . TENTS TRANSFERRED,TO«
' I ;