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HomeMy WebLinkAboutSeptic Pumping Slip - 57 MILL ROAD 3/1/2016 _ Commonwealth of Massachusetts � � - u City/Town of Merriman �� ������I � System Pumping Record �., Fortin 4 �;%.� ,,. UVN t F NORTH ANDOVER VI R I DEP has provided this form for use by local Boards of Health. Other fc r�sA yt;�j3Redt bUt t information must be substantially the same as that provided here. B Is arm, 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 Flealth 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 9 � A � use the return o ___— � <ry' _ MA M90 key. City/Town State Zip Code rat 2. System Owner: S 'Y► Narne -- renrn Address(if different from location) Cityfrown State ` Zip Code / �''�„- l o U 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: �I 6. System Pumped By: Name Vehicle License Number BORACZEK"S SEPTIC & DRAIN Company 7. Location where contents were disposed: Signature of Hauler Date Signature of Receiving Facility Date t5form4,doc-03/06 System Pumping Record•Page 1 of 1 FORM Q - SYSTE"A PCJWNG RECORD wu ���� off " commonwealth of Massachusetts Massachusetts JG F-TH ANDOVER S stem �rn In �ec I°C� 141 UTH otar� Ir LF ystem ocation I i � 1 I Type Emergency ❑ Routine P No ❑ Yes � Yes ❑ Septic Tank; Cesspc ��I: No ❑ . � / yYC,c'��a� _ gallons Date c :` Pumping: Quantity Pumped: Permit S%•stei:: Pumped by (Company): Conte .ts transferred to: Cont. .)ts disposed at: /r Pumper Signature Date ._3 P p Cony ition of systeMoLh comments: d k- Df3 AYPROYED MR-St I.J0719S FORM 4 SySTEIA Pt.,liv)MG RECORD Commonw0alth Of MOssacha, Mpssochusels Y Ica L E yst � wn c , ,� 6 � � t�e Type; ,�►eI� nay ���I Yes Ccsspc ol: No Yes qk TOO: NQ aIIons Date r. :' Pumping: �a ti iu�nntity Mumpcd: S�stei pumped y (COmp Y). UPACZ� Permit Contc .ts transferred to: Cont,, As disposed 8t: ire pumper 5i stun Date � — p Concitien orsystewothar co nts: r 1 DU AYPROYO NAM i RECEIVED Massach � s air" jjg CitylTown- of ;T mp NORTH ANDOVER . o...� _.�.. �..�..... ... Fore be ' ft a . LWOW c awpuw.um A olds r Stuf dip p b, ` ma un _ iirrt .3 chi / )2. l nft Feu d; &SMpUG Tank U Tight Tank 4. U%sftK T-00 Fille . nt? Yes l No It ,wm it donned? yes NO . con of Bywmm. tram u i n _. ?. Damon n wore d r Y�su.rvw ° ✓wim maw Mmi.awiniMmmi�" pm� f MMMA'don,ROM 0.R FORM Q SYSTEM PCJNCPG RECORD Commonwealth of Massachusetts . � �.. ' Massachusetts G 12 01 System P4MOr g Record r� ystem ocation �... Jysif;1 WneC z. .., _. r ..._.. r i Type: 1. Emergency ❑ Routine CX Cessp col; No . Yes ❑ S(.ptic Tan,},: No ❑ Yes Dace c :' Pumping; vim'2 Quantiry Pumped, _ gallons BO CZ '. systei,: Pumped by (Company): -- _.. __. �.: �� Permit �; Cone, -.Is transferred to. C��ni..its disposed at. Dutc ,y `„_.R./- .-04umper Sienamre ✓ - Conriti©n of system/other comments; DAP APPROVED PORN1 12lo7l9S Commonweatth ,, SSACHUSETTS System Pumping Record Form 4 k�o�j DEP has provided this farm for use l Boards of Health. The System Pumping Record must U -t0- I.13o rd- f-Heal r-or other app A. Factfity Infonnation ) 3 20 fbr sonthe p f.use S only the tab key Address C /lawn State use the return ' — Zip Code key. .2. System Owner Name Address(if diffierant from laaattan } CTty/"T'own �tatm —ZIP Cade C'.. TelCph0ne Number ping 9. Date of Pumping S t notes 2. QUan fty Pumped: -3. Type of system: Ges.�pool(s) Septic Tank �f Tight Tank Ll Other(describe): 4. Effluent Teri Filter presents Yes El. No If Yes,was it cleaned? Yes No 5, Condition of System: .. S. Systern F'wrlTrtped BV: r —License Number 7. Location where contenfa wor .dTspo d:,., r�";�� ����t,e�.w';ems• �'�°� � "" FW I ("'1'L'te� l u�..®x.�.m...m.,. ,,.r.u,•,_ ,-_..—._aoc......��e._�..,... ��...a....4.�� k;L �® f7ttp;/iruw'�.maA8.goV/ g rJ�t� p/wst r/epproVaIs/t5farms,Wriffinspeot Pbtc> d.doo t�raro� Stern Pmmp' ^page 1 of 9