HomeMy WebLinkAboutSeptic Pumping Slip - 16 BEAVER BROOK ROAD 12/23/2015 :
ComEIVE
monwealth of Massachusetts RE
City/'Town of NORTH ANDOVER MASSA H1� 1'tiV'
System Pumping Record `TttNTrtAta :f OR
Form 4 H A�Two A TMENT
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:
When filling out 1. System Location:
forms on the . � � .®_ bK computer,use
the tab key Address
to move your Of
cursor-do not c �
use the return CI /Town State Zip Code`
key. 2. System Owner:
Name
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
n
1. Date of Pumping Dec 2. Quantity Pumped: Gauons UU
3. :Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
�] Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. rj em Pump By:
Vehicle License Number
Company
here contents were disposed:
ou Location y-\ �\ r' %4 1 1(
gna ure of Hauer Date
http:/AwAv.mass.gov/dep/water/approvals/t5forms,htm#lnspect
t5fom.4,doc 06/03 System Pumping Record-Page 1 of 1
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DATE OF PvMpNo:
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TOWN OF NORTH ANDOVER
PUMPING SYSTEM
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DATE• "� r u .� J
I ` SYSTEM OWNER&ADDRESS SYSTEM LOCATION
- (example: left front of house)
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., DATE OF PUMPING:
` ^ _,.) QUANTITY PUMPED � ' '�e1 GALLONS
+ CESSPOOL: NO YES SEPTIC TANK: NO_ YES
NATURE OF SERVICE: ROUTINE. - EMERGENCY
PSERVATIONS:
'GOOD CONDITION FULL TO COVER
HEAVY GREASE � ' BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
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SYSTEM U r
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� QNTENS TRANSFE D TO
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