HomeMy WebLinkAboutSeptic Pumping Slip - 85 BOSTON STREET 11/18/2015 I
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Commonwealth of Massachusetts AUG" 03
City/Town of A ft
System Pumping Record
Facility Information:
System Location:
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Address
City/Town State Zip Code
System O ev
Name:
Adress(if different from location of pump)
City/Town State Zip Code
-7
Telephone Number
Pumping Record
Date of Pumping s Quantity Pumped / 4'��� gallons
Type of System ``rµ Septic Tank Grease Trap Other (what)
System Pumped by: L� .o
Company: ROOTER MAN 46 Portland Street Lawrence,MA 01 843
Location where contents were disposed:
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Signature of Hauler Date ,�
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Commonwealth of Massachusetts
City/Town of h"
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System Pumping Record 70vvtq ' "5
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Facility Information: u
System Location:
8�-
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Address
City/Town State Zip Code
System Owner:
Name:
Adress (if different from location of pump)
City/Town State Zip Code
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Telephone Number
Pumping Record
Date of Pumpin 4 - Quantity Pumped , _a L gallons
Type of System--k -Septic Tank Grease Trap Other (what)
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System Pumped by: 311h
Company: ROOTER-MAN 46 Portland Street Lawrence, MA 01843
Location where contents were disposed:/ 7 P
Signature of Hauler Date
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`! _Mn.
/Town of
System Pumping Recur
S'yntern Location: 'Zili-Ii 2-@
Add ess
State 9f
r ,;`stem ✓%?3er:
42
A Tess 'if different fr csm locatior, of pump
State 1 ',C
Telephone i ul.,
r � Record
I1a .t. of Pumping � l_( , 1 ..., _Quantity Pumped
L,..
y ric of S ystern_ Septic Tank Grease Trap Other h t;
SYstern Pumped by �� a
`,oinpany: ROOTER-MAN 46 Portland street Lawrence, MA 0184'
is>vatscon � here contents were disposed:
(if Hauler p�"` De1ti
Commonwealth of Massach set1j) 1 �E E
_ CitylTown of � �ti. Bel .. 006
System Pumping ecord m
Form 4 ��a:�nrF"�.k 01. �F'�H r'['uov/ER
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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
vvhzn filUng Qut 1. System Location:
form on the { /
computer,use 1 4 ✓
only the lab key Address =�__...-
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to move your not n4 V \ t V.'4,
cursar-do not --=�
use the return City/Town State Zip Code
key.
2. System Owt( w
Name --
�l�,�� Address(if differenk from location)
Citylrown State „ Z Cade
7
Telephone Number
S. Pumping Record
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1. Date of Pumping � �'� "6z"t
Date 2.,Quantity Pumped: Gallo
3, Type of system: ❑ Cesspool(s) 'Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If
-YP5, wad it leaned? ❑ Yes ❑ No
5. Condition of System:
6. Systnpu'Up OQy-
me l Vehicle liceen Number
Company .,
7. Location where nte t s w?re df osed:
Sig aturo of Hauler Data ' —'—
t5form4.doa 06/03
System Pumping Record-Rage 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
1 n Arlt— (example: left front of house)
DATE OF PUMPING: 4 o QUANTITY PUMPED SC-) GALLONS
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CESSPOOL: NO YES SEPTIC TANK: NO YES
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NATURE OF SERVICE: ROUTINE EMERGENCY
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OBSERVATIONS:
GOOD CONDITION % FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: bL t�
COMMENTS:
CONTENTS TRANSFERRED TO: p �