HomeMy WebLinkAboutSeptic Pumping Slip - 113 BRIDGES LANE 1/6/2016 � `, Commonwealth of Massachusetts
City/Town
of w.j 1 .
_ System Pumping ReGord NORTH AN DOVE R '1:
•y
Form 4
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:
When filling out 1. System Location:
forms on the
computer,use _ __ __ tY _ --- __ __._._ ...__. ....---------
only the tab key Address
to move your
cursor-do not Cityrrown - - State Zip Code
use the return
key. 2. System Owner;
--- —
Name
�^ Address(if different from location)
_-Citiyrl'own-__ State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - ' — — 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) E -Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ej-No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
��-
;r f
--- -
Name Vehicle License Number
Company
7. Location where contents were disposed: Norffi Andover, MA.
Date
Signature of Hauler
Signature of Receiving Facility Date
15form4.doc•03/06 System Pumping Record•Page 1 or 1
TOWN OF
ED
SYSTEM PUMPING REC ECEVED
• i fi " 3 200
DATE: C)
T0711VFN LT
HE
m4 0 T ENT
NT
SYSTEM OWNER 8a ADDRESS SYSTEM LOCATION
(exampled left front of house)
PT
( s <' L�A
DATE OF P ING: ` ` U QU rY P ED : T�, �,00 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES L
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIMELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTIHE R(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, c.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S. Lowell Waste
Commonwealth of Massachusetts
MassachuscUs
System Pumping r
System Oweer System Location
i ( l 3 �
Date of Pumping: lC� Uc" Quantity Pumped: S gallons
Cesspool: No Yes U Septic Tack: No L-1 Yes
System Pumped by: varedart License #
Contents transferrred to : Greater Lawrence Sa"Itary Vistrict
Date: — - Inspector