HomeMy WebLinkAboutSeptic Pumping Slip - 70 BEAVER BROOK ROAD 12/18/2015 Commonwealth of Massachusetts
City/Town of NO. ANDOVER RECEIVED
System Pumping Record
Form 4
TOM OF NOR' HAN' OVER
DEP has provided this form for use by local Boards of Health. Other form IJILML T
information must be substantially the same as that provided here. Before Sing this 'ri-n— 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
Important:
When filling out 1. System Location:
forms on te the 70 BEAVER BROOK RD.
computer,use AVE
----------------
only the tab key Address
to move your NO. ANDOVER MA 01845
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
DON RITCHIE
....... ................ .......
Narne
Address(if different from location)
City/Town State Zip Code
Telephone Kium�br---
B. Pumping Record
1. Date of Pumping 11/12/10 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) 12/septic Tank F-1 Tight Tank
❑ other (describe):
4. Effluent Tee Filter present? El Yes D/No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
James H. Currier H79 406
Name Vehicle License Number
J's Septic & Drain
Company
7. Location where contents were disposed:
GLSD
1102/10
Signature ure o Date
t5forrn4.doc-06/03 System Pumping Record-Page 1 of 1
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
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S�� EM OWNER& ADD SS
SYSTEM LOCATION
✓�J� /7 �// (e ropier left front a house)
DATE OF PUMPING: QUANTITY PUMP'E'D GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE. ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE 'BA + +LES IN PLA E
ROOT'S LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
)
i6.
c P.
SYSTEM PUMPED PdY;
COMMENTS: r
CONTENTS TRANSFERRED TO: G� �
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