HomeMy WebLinkAboutSeptic Pumping Slip - 107 GRAY STREET 2/23/2016 Commonwealth of Massachusetts
r City/Town of
a System Pumping o r
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 farm, 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 p Loca
--- Ion:
forms on the l :.
computer,use
C ..
only the tab key Addres
to move L� � � �"S
Y our .. _
cursor-do not -- ----- - — --
use the return Zip Code
CdylTown State
key. 2. System .
Owner:
L _ '
wne
Name
Address(if different from location) —
City/Town State Zip Code
(° -----
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gain
1 Type of system: ❑ Cesspool(s) (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 Syste
6. System Pumped By:
Name rte} Vehicle License Number
Company
7. Location where contents were disposed: G.L.S.D.
-.�
Signature of Hauler Date '
Signature of Receiving Facility ----- Date -
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Ma!ssachusetts
City/Town of rd NORTH ANDOVER
System pumping Roco
Form 4
Q has provided this form for use by local Boards ealth. Other forms may be used,but the
information must be substantially the same as that prow ded 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: 1. S;ystem Location:
when filling out
forms on the
computer,use
only the tab key Address
to move your PN��C State Zip code
cursor•do not
use the return
key 2. System 0 ner',
n Address(if different a
from ideation}
Zip Code
CilyiTown _0LjJe-68 5 A-
Telephone Number
B. Pumping Record
0—' L 2. Quantity Pumped- Gallons
1. Date of Pumping pate
Grease Trap
3. Type of system: ❑ Cesspool(s) �96eptic Tank El Tight Tank Fj
Other(describe):
4. Effluent Tee Filter present? Q yes E No if yes, was it cleaned?"9-Yes ❑ No
5. Condition of System:
6. System Pumped By:
vehicle License i4u—rn—ber
I N M
�
Company
7 Location where catLj be disposed:
-§-I—gnajure-6-jRWr-eFvjng Facility
System pumping Record•Page 1 Of
15form4 doc•03106
Commonwealth of Massachusetts
City/Town/Town of
_ Y
System r MAY o,L ,'5 ' 01
Form 4
M
ANDOVER
DEP has provided this form for use by local Boards of Health. Other forms ma .h
information must be substantially the same as that provided here. Before usin
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: rn Location:
When filling out System 1.
forms on the
computer,use -- - -- "-------- --- ----- #
only the tab key Address p
to move your '° -.---- -- - -s✓ i Z( I a
cursor-do not _- -City/Town t.--- - Stale p e
use the return
key.
y owner:
� 2. System f �
Name
+� Address(if different from location)
State Zip Code
City/Town . "
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallo- ns
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --- - -
4. Effluent Tee Filter present. [ °"Y
es E] No If yes, was it cleaned? """Yes ❑ No
5. Condition of Sys m:
6, System Pumped By:
Vehicle License. �µw
-~ -. - -- - -.- Number
Name
- -I ---
Company
7. Location where contents were disposed:
------ - - ------- _.-- ------—
---------- --- - ---- Date
Signature of Hauler
------ -------- -- --- - - Date
Signature of Receiving Facility
System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
r City/Town of NO ANOWE'st
a System Pumping Record
fi Form 4
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 10'7 G
computer,use
only the tab key Ad ire
to move your
cursor-do not City/Town� Stake Zip Code
use the return
key. 2. System Owner:
wc
Name
r Address(if different from location)
City/Town State Zip Code
9'7V- b 3' -9V0 1
Telephone Number
B. Pumping Record
I ' C> 2. Quantity Pumped:
1. Date of Pumping Date Y p 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:
c)(3 c-
6. System Pumped By:
l GQO ckn ( .
Name Vehicle License Number
Company
7. Location where contents were disposed:
(�wu
ry
Signature of Hauler "� ` ° "^ ' t , _; Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
u City/Town of NORTH ANDOVE ASSACHUSETTS
— System Pumping ec r
Form 4
DEP has provided this form for use by local Boards of Health. -Record must
be submitted to the local Board of Health or other approving a thori
A. Facility Information NOV "1 3 o ls
Important:
When filling out 1. System Location: 11`OWN OF NORI 11-4 ANDOVER
forms on the ��� ��� P�II�l1LT-11t 4Df�f�ARI MENT
computer, use .�.w, ._.. ._.. _�.. ��.��A....�.
only the tab key Address
to move your .0 r.
cursor-do not City/T� � r State Y�Zip Code
use the return
key. 2. System Owner: t
Name
�¢ Address(if different from location)
City/Town i State Zip Code
Telephone Number --- —
B. Pumping Record
1. Date of Pumping oats (/44 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): — — --- ---
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
OQ /�V(_ �
6, System Pd By:
� uA
Name ' \ _ Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler hate
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
C'mmonwealth of Massachusetts Form 4 Symern PwI)ping Recor,d
Mussachtmetts
Systern Pumping Record
..........
............... R"91-V-
,System Owner System Location
11 WOV 13 2006
TC)M OF N01R-m, ANDOVER
Hl AL7 H DEPART tw T
Routi-n-e —--— ----------------- ......
........
TypeM1 Emer;,nc
Yes
cesspool: No I............ Yes Septic Tank: No ye sr-Z,
bate of llumpinq' Quantity Pumped:_ Gallons
System Pumped By: Wind River Environmental,H-C
..... ...... Permit#:
Contents Transferred fo:
............. ........ ......... ------
I,,----�............ ......
Con-tents Disposed at
..........----..................................--..............
............. ---—------------ ........... .......... ...............
bate: ----............. .................. Pumper Signaiure: ........... ......
Condition of Systern/Other Conovients ................. .... --------------................
............... ...... ............... ...................... .............
.............. ................ ...... .......... ..........
............. .................... .......... ........... ........ ...........
...................... ............... .............
bep Approved Form 12/07/95