HomeMy WebLinkAboutSeptic Pumping Slip - 30 BARCO LANE 12/18/2015 1
Commonwealth of Massachusetts
City/Town of North Andover
u `
System Pumping Record � 1
Form 4 py
DEP has provided this form for use by local Boards of Health. Other forhns,)in ay bq,used, but the
information must be substantially the same as that provided here. Before ustng°th4s fbt;r�t check with your
local Board of Health to determine the form they use. The System Pumping�escirtf must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CM 15.351,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, r �,
use only the tab 30
key to move your Address
cursor-do not North Andover Ma 01886
use the return City/Town State Zip Code
key.
rab 2. System Owner:
Name
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat �8 2. Quantity Pumped: Gal ons
3. Type of system: ❑ Cesspool(s) -Er 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:
6. System Pumped B
Name Vehicle License Number
Stewart's Septic Service
Company
7. ere contents were disposed:
Stewart's Pre- atment Plant, 20 So. Mill Bradford, Ma 01835
of Hau r Date
e Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
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T 1` NORTH ORT ANDOVER
YSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: ' 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 CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: