HomeMy WebLinkAboutSeptic Pumping Slip - 29 ANNE ROAD 12/18/2015 (2) I
Commonwealth of Massachusetts
. 1
City/Town of
System Pumping Record
:.> �
Form 4
DEP has provided this form for use by local Boards of Health. Other form °may `userY;�bhe�
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 j
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling Location: .
computer,uSet 1 System LOC
only the tab key
to move your
cursor-do not Citylrowm state Zip Code
use the return
key. 2. System Owner:
Name
n Address(if different from location)
City/Town State 1 VN Zip Code
Telephone Number
B. Pumping ec r
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes oy. If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
. . L C
6. Systerp Pumped By:
Name d Vehicle Ucense Number
Company
7. Location re cont e s w sposed:
4
. 7-e
Signature of J Date
t5form4.doc•06/03 System Pumping Record^Page 1 of 1
f
Commonwealth of Massachusetts RE ,� . 1 .
M
City/Town of
a a System Pumping Record
JUN 1 1 2007
Form 4
DEP has provided this form for use by local Boards of Health. Other form y b&-used' bu
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
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key +�
m edo t
or oy teas
to `r,.
use the return City/Town State Zip Corse
key.
2. System Owner: ,
VGa
Name .
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping r ,
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) optic 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:
Name Vehicle License Number
Company
7. Location where contents were osed:
>,.
4�7
Signat r of Vaulf Date
t6form4.doc•06/03 System Pumping Record 4 Page 1 of 1
Commonwealth of Massachusetts
City/Town of I
System Pumping Record
k�fiAY % 2 20 ('1
..` Form 4
V Sv.
DEP has provided this form for use by local Boards-of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
filling When y atiow
forms tart use t 1. Sys m�
only the tab key Address
to move your
cursor-do not
use the,return Cityrrown State Zip Code
key. 2. System Owner:
Name .1
�I Address(if different from location)
Cityrrown State
/AL ., Zip�ode
Telephone Number
B. Pumping Record
1, Date of Pumping pate 2, Quantity Pumped: canons
3. Type of system: Q cesspool(s) eptic Tank ❑ Tight.Tank
❑ Other(describe)'
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi of SstemJ^ .
6. Syst�rn Pu �y. `�
Name Vehicle License Number
Company --
7. Location where contewerposed:
,`
Signal re H ler Date
h.ttp://www.mass.gov/dep/water/approvalt,/t5forms.htm#inspect
t5form4.doc•06/03
System Bumping Record•Page 1 of 1
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: '
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
t�(;' (example: left front of house)
Ul
DATE OF PUMPING: `�( C1 QUANTITY PUMPED t c,(Y-, GALLONS
I
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE / EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIHTELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
e
CONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
P—A
DATE OF PUMPING: �-"--'�A�'61JANTITY 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:
Commonwealth of Massachusetts
JJJ , Massachusetts
System Pumping Record
System Owner System Location
t
Date of Pumping: - r _;_z Quantity Pumped: gallons
Cesspool: No H" Yes [] Septic Tank: No [] Yes [ �"
System Pumped by: Ed&," OF License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
('ooh mmiwealth of Massachusetts
Massac,lutsetts
System Owiier System Location
V� _ —Date of t'umping: Quantity Pumped: gallons
Cesspool: No 1°°1 Yes I_) Septic Tank: No I_J Yes —
System Pumped by: varedar6 License #
Contents transferrred to : Greeter Lawrence Serlitery Vistrlct
Date: ----- -- —!nspector ---