HomeMy WebLinkAboutSeptic Pumping Slip - 40 STERLING LANE 3/3/2016 Commonwealth of Massachusetts
u City/Town Of North andover
_- System Pumping Record
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 IrJormation
Important:When
filling out forms 1. System Location:
on the computer,
b
use only the tab . .,..
key to move our Address
cursor-do not N. Andover
use the return Ma --
key. City/Town State Zip Code
kD
2. System Owner
. .,.
�1�Q�,S Name
ietun��
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: -
Date Gallons
3. Type of system: ❑ Cesspool(s) �[2' 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
Stewart's Se tic Service
Company —
I�
7. Location where contents were disposed:
Stewart's Pre-treatment 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 f
City/Town of No.Andover -
System Pumping Record � MAY
Form 4
IOV7lNE)F 1p0I,fh61'i11 OVGr
6f (ItiI�P d'fflP(�IIfPd
DEP has provided this form for use by local Boards of Health. Other forms may^ e used, bud 4�ie
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 ❑ �� � 0 ❑,, -—
only the tab key Address +- — —
to move your No.Andover ww Ma 01880
cursor-do not - ---- ------
use the return City/Town State Zip Code
key. 2. System Owner:
Name — — -
— - — — - --------
relwn 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 XINO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
------ -- ------ - --- --- ---- —
Sign tur Ha ler Date
Signa ure f R eiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
cn
a®
a a
z f=
ED
w 1 x
(p z
� U° r
` z
o W? a
n 20
Pa
U
E U
� C1,
� I I
0
V)
c
V
� M �
.— .— N : r r ° T co or
SYSTEM PUMPING RECORD
+� I'CM OWN'RR AI D(t E SS S'�,ST efmmLOCA /10f
(example; Ick iron( of hou�o
AJA,J
P
Nu.
u.V1'13 OF PUMPING; q . ��. QUANTITY I UMPED� ,� G'P LLt�w ,
c. l..,), I'acaL: Na Yes . _ SPTIC TANK: Na _ . Yes
-,TURF OF SERYICE; ROUTINE EMFRCENCY
GOOD CONDITION, F`ULL TO COYER
)-iF:AYY CREASE BAFFLES IN PL,ACI,'
FOOTS LEACH FIELD RUNI3AC'K... _
C, XCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER P FIR R (EXPLA-IN)
>ti'ti'I'Lh1 PUMPCD BY,
C 1vvl rmTS:
l U'�'1' TItANSF C, I Z R E D TO: � _