HomeMy WebLinkAboutSeptic Pumping Slip - 65 BOSTON STREET 12/18/2015 Commonwealth of Massachusetts
W City/Town of
7-ALTH„M
0 1
System Pumping Ci AN �
rOWN t Form � P AWr
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 front of ho rl ht front of hous w
y g e, le de of house, right side of house, Left
rear of house, right rear of houset,`teeft side--of builder , right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State-,�f� �❑ d�
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑--S-e ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Coed” io of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Lo nhe e contents were disposed:
G.L.S.D Awell W ater
Signa re f auler Date
t5form4.doc-06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
City/Town ®f �
Pumping System Record` Form
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
Important:
When filling out 1. System Location: " �forms on the
computer,use
jv
only the tab key Address "" _ C
to move your C
cursor-do not a ty/Tawn State Zip Code
use the return
key. 2. System Owner:
Name
ran Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record G� .
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 0-146 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pu ,pedw By:
w F--�5
Name vehicle License Number
-
Company`
7. Location ere conteswer sposed:
w.
Signatur of ul r Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth lth f Massachusetts
H City/Town of
System Pumping Record Z0,
Form 4
®EP has provided this form for use by local Boards of Health. Other forms may be used, but the
infonnation 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 I
only the tab key Address
to move your
cursor-do not Cityrrown St afe Zip Code
use the return
key. 2. System Owner: p
Name
Address(if different from lacation)
Cityrrown State Zip Code
Telephone Number
Pumping B. c®
1. Late of Pumping pate City Pumped: Gallons
3. Type of system: ❑ Cesspool(s) n Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? El Yes ❑ Ks o �4~ If yes,was it cleaned? ❑ Yes ❑ No
5. Condition f stem, p � C2
6. System Pu py' ,
Name -, Vehicle License Number
Company
7. Location wher contents were disp ed:
Signatu ler Date
t5form4.doc>06/03 System Pumping Record•Page 1 of 1
i
TOWN OF NORTH ANDOVER'
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
,.
(example: house)
exam le: let root o
DATE OF PUMPING: QUANTITY PUMPED „.a. GALLONS
CESSPOOL: NO —1.11",
SEP'T'IC 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: