HomeMy WebLinkAboutSeptic Pumping Slip - 60 BEAVER BROOK ROAD 12/18/2015 Commonwealth of Massachusetts
a
City/Town of
i"
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.
A. Facility Information
1. System Location: Left/Right front of hous ,;Left Rig rear of ho , Left/right side of house, Left/
Right side of building, Left/Right front of bug, Left ig rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
CitylTawn ' State i C de
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 present? ❑ Yes No 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. Location where contents were disposed:
GLLS-P Lowell Waste Water
Sign t e Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
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TOWN OF NORTH ANDOVER
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SYSTEM PUMPING RECORD
DATE: - . ._..
SYSTEM OWNER & ADDRESS
a SYSTEM LOCATION
r (example: left front of house)
DATE OF PUMPING; "
QUANTITY PUMPED , GALLONS
CESSPOOL: NO °°"'" YES
_ SEPTIC TANK: NO --______ YES
NATURE OF SERVICE: ROUTINE � y
EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE FULL TO COVER
ROOTS ------ BAFFLES IN PLACE
EXCESSIVE SOLIDS �— LEACHFIELD RUNBACK
SOLIDS CARRYOVER_ FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY:
_'OMMENTS:
U , .
ONTENTS TRANSFERRED TO: