HomeMy WebLinkAboutSeptic Pumping Slip - 75 BOSTON STREET 12/18/2015 l
Commonwealth of Massachusetts �� . ,,
City/Town of �,�E ��[,�`�� � ,
System Pumping Record i
Form 4 i f" " j
� EM �r i E�='" .
DEP has provided this form for use by local Boards of Health. Other rye ,
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 house, Left/Right rear of hous<Leo righ s@jg house Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name ,.
Address(if different from location)
City/Town State zip Code
Telephone Number
B. Pumping Record
I <mm e4>
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 ❑ la ^r If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiop qf System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
SignAtute I Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
i
Commonwealth of Massachusetts
REC
City/Town of
System Pumping Record
N("N (:11 21,010
Form 4
TOWN OF NORTH ANDOVER
. EbEt t
DEP has provided this form for use by local Boards of Health. OtheL:::
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 house, right front of ho<e-,l(�ft'sid-e—of h-o�usejlght side of house, Left
rear of house, right rear of house, left side of building, n§`ht-rear-Gf-b-W1d`ffin`g',�under deck.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stase
8 ,3-L/L/
Telephone Number
B. Pumping Record U—
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 If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiqn of System:��
K J 6 f V-'-
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. ere contents were disposed:
4G �')'� awell Was J6 W*er
LS
Signatu Htuler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
. (example: left front of house)
r
OF PUMPING: QUANTITY PUMPEDIZO-c-) GALLONS
> K: NO YES
CI�SSI UOL, NO �/ YES SEPTIC TANK:
NATURE OF SERVICE: ROUTINE l/ EMERGENCY
013SERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
S1' TEN,I PUrvIPED BY .
CONINIENTS:
C:ON E'NTS TRANSFERRED TO: