HomeMy WebLinkAboutSeptic Pumping Slip - 45 BEECHWOOD DRIVE 12/28/2015 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
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 the r,computer,use 45 BEECHWOOD DR
only the tab key Address
to move your N.ANDOVER MA 01845
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
L-COM
Name
Address(if different from location)
City/Town State Zip Code
978-682-6936
Telephone Number
B. Pumping Record
1. Date of Pumping 08/15/15 2. Quantity Pumped: 5,000
Date Gallons
3. Type of system: ❑ Cesspool(s) FEW Septic Tank ❑ Tight Tank
F-1 Other(describe):
4. Effluent Tee Filter present? /Yes ❑ No If yes, was it cleaned? RN Yes ❑ No
5. Condition of System:
GOOD
6. System Pumped By:
ROGER ROBEY 7626AR
Name Vehicle License Number
SOUCY SEWER SERVICE INC
Company
7. Location where contents were disposed:
G.L.S.D.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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 the r,computer,use 45 BEECHWOOD DR
only the tab key Address
to move your N.ANDOVER MA 01845
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
L-COM
Name
Address(if different from location)
ity/Town State Zip Code
46
978-682-6936
Telephone Number
"\\41,"Pumping Record
1. Date of Pumping 10/13/15 2. Quantity Pumped: 5,000
Date Gallons
3. Type of system: ❑ Cesspool(s) nE Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? 9 Yes ❑ No
5. Condition of System:
GOOD
6. System Pumped By:
ROGER ROBEY 7626AR
Name Vehicle License Number
SOUCY SEWER SERVICE INC
Company
7. Location where contents were disposed:
G.L.S.D.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record•Page I of I
i
i
Commonwealth of Massachusetts 1
w City/Town of NORTH ANDOVER, MASSACHUSETTS
a System Pumping Record
Form 4
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 45 BEECHWOOD DR
computer,use
only the tab key Address
to move your N.ANDOVER MA 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
red L-COM
Name
' Address(if different from location)
Ciyn State Zip Code
wg ff r' r y
,a " 978-682-6936
�r ) Telephone Number
bW
t.
B:,` 'urnping Record
01/06/15 5,000
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) X Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? F Yes ❑ No
5. Condition of System:
GOOD
6. System Pumped By:
ROGER ROBEY 7626AR
Name Vehicle License Number
SOUCY SEWER SERVICE INC
Company
7. Location where contents were disposed:
G.L.S.D.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
Form 4
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.
i
A. Facility Information
Important:
When filling out 1. System Location:
forms the
computer,use 45 BEECHWOOD DR
only the tab key Address
to move your N.ANDOVER MA 01845
cursor-do not Cityrrown State Zip Code
use the return
key. 2. System Owner:
Q L-COM
Name
Address(if different from location)
5 ity/Town State Zip Code
978-682-6936
(r Telephone Number
1Y
$. Pta�niping Record
1. Date of Pumping Date 005/06/15 2• Quantity Pumped: 5,000
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? ❑■ Yes ❑ No
5. Condition of System:
GOOD
6. System Pumped By:
ROGER ROBEY 7626AR
Name Vehicle License Number
SOUCY SEWER SERVICE INC
Company
7. Location where contents were disposed:
G.L.S.D.
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record•Page 1 of 1