HomeMy WebLinkAboutSeptic Pumping Slip - 92 BRIDGES LANE 1/6/2016 RECEIVE[)
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Commonwealth cat Massachusetts
City/Town of No Andover SIN.N '10 01 4
o
System Pumping Record TOWN u' Nur,N-1ANP:1OVER
Form 4 HEAL,n @ 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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted ti:
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not No Andover
use the return Ma
key. City/Town State Zip Code
2. System Owner:
Name
ienvn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
10,
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatril ent° lant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Receivm Facility! Date
Signature of .
t5form4.doc•03/06
System Pumping Record•Page 1 of 1
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TOWN OFNO$.TH ANDOVER
SYSTEMPUIviPING RECORD
'DATL
SYSTEM OWNER&'ADDRESS SYSTEM LOCATION
d
DATE OF PUMPING ! ®� �' QUANTITY'PUMPED
CESSPOOL NO YflS SEPTIC TANK NO YES
�4
NATURE OF SERVICE:s RQt�l'I'1NE EMERGENCY
OBSERVATIONS:' ,, .. ..;.~..
GOOD CONDITION`.'; ...;. FULL•T0 00VER
' HEAVY GREASE ' BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN �..
. r _
SYSTEM PUMPED BY � � % r
COMMENTS:
CONTENTS TRANSFERRED T® - '
TOWN OF NORTH OVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: 4/-&Oc QUANTITY PUMPED a GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE V EMERGENCY
OBSERVATIONS:
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: