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HomeMy WebLinkAboutSeptic Pumping Slip - 492 SALEM STREET 3/4/2016 Commonwealth of Massachusetts City/Town of 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. A. Facility. Information 1. System Location(! Righ ronfof h e left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner: Name Address(if different from location) Cityrrown ' State Zip Code ; Telephone Number —; B. Pumping Record 1. Date of Pumping l ( s 2. Quantity Pumped: C�` Date Gallons 3. Type of system. ❑ Cesspool(s) EY Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Of MCI' 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Location where contents were disposed: aL S: Lowell Waste Water e-- f L + SignAtufe 9t Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 /r N/ GD)f r , 1. S US T7 k OEP hai pfoYlded lhli loan IoY Sao ';' locos 8onrcr o1 fO "'`NO NORTHANDOVER o r fr,IIIQCf IQ Ufa Ioc I ca1c. E1 n0J In Q1,1 A. Faculty In(orma�lon ____ location; I,�,4 n Wm �(7� � • SYa,vm �wivr� Ql � rr / I. O ,i (� f I'• -71141 (II OVfjfinl fernIQG O n) , Tr o�npnr n,rnprr l I P,umping R�a�o rd , y't -- • 3, rXPQ 910 X)lom:', 0 Ca�saooi(y) Sfial!c Ton, r�� �C7'-Othar�(dvscrf�bv��:� a Emvanl To "•\. sa!,���Ilv('Of I, (l Yp9 o t y©s nee !, c aana�� YPS / n ! Q a . 6.'. Sy .rpti'mpvd 8y: 'II�J '' '' I yIIICJ4 ',� f,;l� can P.0 ' �1„r' ;' Y•;I�'r'Y � '� r '� � I � on.�rhvr�'oo�lanla',wvO 015pomv n �W- lz1-)2 7111 ^��r.masa.8•or/d0 alvr/app(ore)V, WQrm3.PI nnin5poC; I , /y^I�`,�'y� +••`Nttl"� ( r���}}�1+ t 4 , � I •1,8 D' l./E wi ® I-1 .......... ,frV'A!�r�}'��,4I!���!�r(ilfff���l �`,Ivgr'��'t j YI1( r1141' ,,+ Llly"{rrl r,'r r!;,6 ,. .r P'. as kooOded �hfi.form for uvs by local Boards of Ho' ealth be :ubml�ted to.thQ.local'Board of Health or other a umping Recotc rr_. r. !,,.; ,rir •,;',!,M,;;I',;;,s;s ',.,, pproving authorlt ;,^ A; acIIIty,,lnforrUtlon ^r`a.,,,W11�Ibm+/IM 4 1�1 ��:+ �.I,l}'I.•.� , ftmv out 9,.;; System Lo,"atlon;' Q,*thv tab kvy Addrvsm W mono yow uie"U�'r bturr?;,v;`: '..,,:,Cily//�c�wrt 4 :,r.'�1fr4114� r1{VIZ:,1'Ai+•r;r; "5't4.Vt1°;{''d"')i!;'n�,,�l'Lr ,rJ." I + 'e:i�, .,� p 51Om Nor."" ,ti�).. i+4YSII,,f�.ti Y',��I'Y` +,� Yi{ ; 'I, ,l/1ti11j'Ir V1�,1• , , 'yLY • '`"'�1:r i�r��r,I�r.,y,I;','/11;�; j,���wr��N � �Q,:'�� I l,jlyy'flV,r 4q v,.�.,.r � �.�y� f�'/®/ Addra;s(1ldllfvrvnl rom loceUon) f�✓ jr, it ,I ,, Staty O ` Tolvphono NVmbo( �'�j rr'�I,Jy` .t,{;f,Y!�'f'��Ylryti';'y1,1:rr`e�:'�;:�i;•'t,�ltt�' ,� 91 C74 of Pumpinq` 21`QuanUty Pumped; �!•',,�` yRe p'f,ayslem; C) Cesspool(s) eptlo Tank C Tight Tank ' + '' �), 'ti'' �f%,ri:,,74Y ♦Arrl4i'4 ,,,, r '`'4 v'«•' f u' ON T68F' y�lty'I,I',r s e t? t r j4', 'a'llll 11+IV'{/'ril lr;�ly� ,tp��Y,,,,,r1 yes, •cleallad? Yes r,'o '';,��:lr�tit✓,Iry�`'I i tr,I .. 7 I • ,, . .^,yl '' r 111 r I'• „.... Y w r, I ml, Y • 1�.(}`I,)ya4 a,,}!�',�(iJi�r'}+ySLi���1,, ,,• , ,17'n'i !rI•I,tG'lQ,,�}YtY�!•S�4tl:/Nl+i'11"�!tirl'�1,�'r' 1Y+1,, °^"",�'''�. r�j„ ', '!'):'i:�'v,''•<',,;y';!'a�';i1 81x1 �+ + ,i"I'; ' � I' S ,. n�,npn ,1, ,,:,,�:.'•�,,y+'r f,,)J;1 ,rf'71 i'4ti��iY�l,Ir.l./'''y' �7. �''�yt{r7 t I�'�` r+�4� ��+��\"'In'�;�I•,1 ' WII ® N 8� �'r'r`�)Y;`I ,;��'"��,,�1�~� trrpwl���r'��. ��'�' �'iril Ily� �f' �'`' "' `I Vvhlcl9�Uy.��� • ,!!,'�y�'t,' iyr{•�!''i7tlyf�'Ir y y.) "I 1 '' r v A'' •'�,. ar,. rl .r',r'Y�,rlf.r i�,j};r,��i�,W�W1f11 AR 1t�r dy rr, f+, if ���•`+y�l ly(1�11:1,,4, � 1"ir'•{Ir+„i11M1 (t�V�'�,w�lp,:;S',�,;I; I 10posed; Jill ,rl � I t II «r.;1'h+ldt^"'•.11,ry i,}I�1" i iYr' f�I.,��,'.'4:+�,I•;1,�;r'I /I S n':L4J� Yr, I+ .1�h}t r{ ,�t�r I I ,I '' ,I I,,�tr }i�•4.rI I / ®sd ',�. ''' ,/I' ,•S �;rrrr,��(,1":�i,tf'SI�r��Wl�ql H�tl� ,I +� 71+Y,o'�,.r.{'�r� r tp hUpylwtivw mass oV%da "� r lr prr yy 8 plwafer/app'rgva�s/t6faims,hlm#Inspect l�fol�4,doa Od�QJ ; ' Syalem P=Ping Rocoro Papa i 'I (�t 10,0;i�ry,,�11YbEyj+"r) li"; - , , il j� ­ .r d. „� t, � �S 1 �t IQ) %6 E .w` M1 Vul n rU � d 6ERhasprolded this form for use by local Boards of Wealt , 6; ecord must be submitted to the loc al Board of Health or other approving uRp �`�'��+° �`�����`' A. Facility Information . , `*^Impiortent, When filling owt' 1 . System Location fowls o n tho' computer,use, on �w IY resat the tab key Add ) cursor do Prot !d f r the return ollyrrown Stag Zip Code key „ 2 �ysten1 Clwner 4 Address(If different from location) City/Town State �q C9 4 Telephone Number Pumping Record w , � • 1 Gate of Pum in ,� 9 oat 2, Quantity Pumped: Gain a 9, .Type®f system:. Cesspools) eptic'Tank ® Tight Tank tither(describe), 4, Effluent Tee Filter present?.® Yes o` If yes, was It cleaned? C) Yes Plo S Condition of System 6y e;n Pumped 6y' �, i Vehicle License Number J C®mpany `7;" Locaffon where oontants were disposed: 4/ V M,� Slnnatur@ of Hauler Date http//www mass gov/dep/waif�r/dpprovals/t5forms,htm#inspect t5fomu4.doce 06/09 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of _ System i Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forrns on the I computer,use mm only the tab Y Addressr � to move your / cursor-do not use the return City/Town State Zip Code key. 2. System Owner. Name fFd"' 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) 2., Septic Tank ❑ Tight Tank tt ❑ 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 Company 7. Location where contents were disposed: �.... Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect t5form4.doc^06/03 System Pumping Record•Page 1 of 1 TOWN OF NORTH ANDOVEN, SYSTEM PUMPINQ R..ECOR I) SYSTEM OWNER dt ADDRESS SYSTEM L.OyC"ATION W� 'm.� 4 DATE OF PU NQ; .... '-'USPQUL; N©_.. "',''YE'3 Septic Tank: NU, YLS NA rUKU OF 3BRVICE: Rou-nNE rte°6 ERUBNCY �M r OOOD CONDI'rioN PULL 'rC) COVER aAVY ASE 9AI' BS IN PLACC, R L FRUNBACK �1iw1,C7 SXCIESSIVE SOLIDS a..._. PLooDRD 'SOUDCAKRYOYER� _. 0'rHPR EXPLAIN Jy®trm Pwnj>od by VUMMl.NTS, �'VN r�N'r� r1�ANSp��KIt�iU ru '�I I T 0 WN 0 F N 0 R TH A N D(D V �' S'-FENI PU N1 1) 1 N, 01 & AVDRESS SYSTEM LCK, 1 PV, 6,jc, Ikuse-, OF P U M P I N C QUANTITY 1) P r v) POOL NO TX/ YES SEPTIC "FAId< NU Y E1 U R L O F SERVICE: ROUTINE E NI F,R C F N Y \T 10 N S COUD CONDITION u I- r() C' H FA V Y C R LA S C --------. !3 A LS I f'� ROOTS L E A CH F1 L)L D i,� EXCESSIVE Sol-IDS F L 0 0 D ED SOLIDS CARRYovEry CQ H E R QX PLA i wi ROM I',) TI(A N S F C, R R L D TO