HomeMy WebLinkAboutSeptic Pumping Slip - 333 RALEIGH TAVERN LANE 3/1/2016 Commonwealth of Massachusetts
- F City/Town of North Andover
System on Record
y0w°�
Form
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 farm 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 forms 1. System Location:
on the computer, ` ( y " n -----------
use only the tab �/t�,t
key to move your Address
cursor-do not North Andover
use the return
key.
City/Town State Zip Code
2. System Owner:
Name
JUN enun �UN 1 �� f 011Y
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -- 1` -r 2. Quantity Pumped:
Date 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:
6. System Pumped By:
Name Vehicle License Number
ewart's Se tic Service
ompany
7. Location where contents were disposed:
Stewart's Pretreatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
-- --- - ---- - -- —
Signature of Receiving Facility Date
t5form4.doc^03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
OEM
City/Town of No Andover
System Pumping Record
Form
ni
DEP has provided this form for use by local Boards of Health:i Other forms gray tie used, but the
information must be substantially the same as that provided her'& Before using this form, chock 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 forms 1. System Location:
on the computer,
use only the tab 333 Raleigh Tavern _ ___ _
key to move your Address
cursor-do not No Andover Ma
use the return — — - -
key. City/Town State Zip Code
2. System Owner:
r� Zall
--- -----------------------
Name
rehan
— —...... -------- ----
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:
( . System Pu" By:
Name Vehicle License Number
Stewart'5ie�)tIC �erVlCe
Company
7. Location where contents were disposed:
Stewar Pre-treatment Plant, 20 So. Mill Bradford, Ma 01335
g uler Date
� � t
Sigr� t6Fhpf,Receivi Feorlity "' Date
a
t6form4.doc^03/06 ❑ System Pumping Record^Page 1 of 1
Commonwealth Of Massachusetts
City/Town Of No. Andover
System Pumping Record
Form 4
provided y r� -���4be us'� "`�b t �`
DEP has rovided this form for use b local Boards of Health. Other fo �� " �` � i
information must be substantially the same as that provided here. Befom�Eetk firfrl;�- e 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 at..ithority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
p
filling out forms 1 S System Location:
on the computer,
use only the tab
key to move your Address _...
cursor-do not No. Andover Ma
use the return
key. City/Town State Zip Code
Q'w 2. System Owner:
Name
etum
Address(if different from location)
City/Town State Zip Code
------ ------ ------- —
Telephone Number
B. pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ----------- ----- ------ ------
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Y No
5. Condition of System:
6. Syste mped By:
.N .
Name ( Vehicle License Number
Stewaq s Septic Service —
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature bf r Date ,..
Signature of Re ei in g Facility Date
#5form4.doc•03/06 System Pumping Record•Page 1 of 1
o Commonwealth of Massachusetts
a City/Town of North Andover
System in g Recor
❑
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:
69�� A°
formsthe �rmt (6
computer, use 333 Rowley Tavern Lane �.�Y)
only the tab key Address A,
fi iTtl i'�fi�ori Ir III
to move your North Andover Ma 018.45
cursor-do not - - --
use the return
City/Town State - Zip Code -
key. 2. System Owner;
�1
r reb Zoll
Name ------ --._.— ---
emn Address(if different from location)
---------------------- --- — ----------- -....- ...._... -- ----
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D/a3e/11 2. Quantity Pumped: 1 5100
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:
X solids
6. System Pumped By;
Bruce Merrill
Name Vehicle License Number
Stewart's_Septic_Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Brad rd, Ma 01835
(_5
1
,.�❑
Signature of Hauler Date
Signature of RecE Date
t5form4.doc•03/06 System Pumping Record-Page 1 of 1
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' }; �',' •:�� , t., � ❑ Tight Tank
1.0ther(desOdb®),
EfflUent Tee Filte resent? Yes
C.p ❑ ❑ No If yes, was It cleaned?
Yes No
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Syalem Pumping Racond Paoe I .
TOWN OF
HATE:
SYSTEM OWNED & ADDRESS SYSTEM LOCATION
(example: left front of house)
..
4-T1-
�\Cx)
DATE OF PUMPING: � � .� QUANTITY PUMPE IS : t.. GALLONS
CESSPOOL: NO ( YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONIDITION FULL TO COVE'R
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER GT"I +R(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFEMWD TAY: .La e D Lower Waste