HomeMy WebLinkAboutSeptic Pumping Slip - 30 WINDKIST FARM ROAD 12/15/2015 i
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T %WN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
is
- (example: left front of house)
vo f,,.
4
r; �'• DATE OF PUMPING: "
QUANTITY PUMPED 0d GALLONS
,Irk�' ` � � ,� ;+` •
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE, EMERGENCY
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS --
LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
I
Q
SYSTEM PUMPED BY:
ti
If� lx
, QMMENTS:
4
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r
,CONTENTS TRANSFERRED TO
p M1
tC 4i I,, r t fit' „
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TOWN OF NORTH ANDOVER
YS TOM � � R A..7... ..,�,,.W.5 d � ....... .. ..... .__..SYSTEM.
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f
V0S L: NO
NA rL)RU OF SERVICE: Rou'rI.N
MAY C CND
CONDrrioN .L hl,'IYj COVER
ROM LHACMELD RUNBACK
VY OUA38 BAFFLES IN PLAC:L,
Oxcusive SOLIDS m Pt, DES
LIDO YCV p,.__,,w. ()THER EXPLAIN
Syet.vm Purrtpoci by ..., •. . .•.•.• .��....c��--,/.°"�/Ca
4'uMMENTS,
Commonwealth of Massachusetts
3. City/Town of North andover
System Pumping Record
Form 4
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 within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important:When
filling out forpms 1. System Location:
on the comuter,
use only the tab 3-�) (0�n
key to move your Address
cursor-do not N. Andover Ma
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping NO 2. Quantity Pumped: 15"I�J
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Ox
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.cloc•03/06 System Pumping Record•Page 1 of 1