HomeMy WebLinkAboutSeptic Pumping Slip - 45 BRIDGES LANE 1/6/2016 h/l
Commonwealth of MassachudMEAIVE
City/Town of
' te u i cord 1�, J�4A ?(,i 2,013
S m Pmpng Re
YS
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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/Right front of house, Left/Right rear of house, Left t side of house) Left
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address
"1K
L IL:�-
City/Town Qj State Zip Code
2. System Owner:
Ali'
Name
Address(if different from location)
Cilyfrown State` / cl- zip ll
Telephone Number
B. Pumping Record
r3,
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 0-1q6 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst m:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
'3
Sign Atufe fHauleV Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
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system R Date of Pum in "lPq 2, Quantity Pumped.ank ❑ TI9ht Tank
!Other o y s I ed?Yes ❑ N If es, wa t clean Yes N( i ❑t1Will Cotitll ion oit� 4, f ,,,y ,; , Vehlcle UCen�e Nuftor
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: /I z /
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
�elt ' (example: left front of house)
DATE OF PUMPING: l QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE "' EMERGENCY
OBSERVATIONS: f
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:
02/03/1997 00:30 5083736611 _....__ STEWART/ANDOVER PAGE 02
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