HomeMy WebLinkAboutSeptic Pumping Slip - 295 FOREST STREET 3/7/2016 Commonwealth of Massachusetts
City/Town of North Andover
a System Pumping
Form 4 �,k"�d�.
1
{h n,
DEP has provided this form for use by local Boards of Health. Other form&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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, ( r
use only the tab
key to move your Address —
cursor-do not North Andover_ Ma 01886
use the return Cit /Town —
key, Y State Zip Code
r�
2. System Owner
Name
relwn
Address(if different from location) -
City/Town - - - State Zip Code -
__ Telephone Number
B. Pumping Record
G F,A /
lid/ _
1. Date of Pumping Date 7 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ,0"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 Septic Service_
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
-- ---- --- -- - ---
- -
,�° _8tgtaa1WUr��of Hauler „.,� .W�,,, Date
Signature of Receive �
9 ng acITity Date - - - --
t5form4.doc•03106 System Pumping Record •Page 1 of 1
.4
Commonwealth of Massachusetts
uL City/Town Of North Andover
System Pumping r aN�, M � fi
❑ 9'
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
y "
on the computer, �
use only the tab y_ `� "
key to move your Address
cursor-do not North Andover Ma 01845
use the return
key. City/Town State Zip Code
2. System Owner:
Name
iemm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ec®r
II -
1. Date of Pumping Date 2. Quantity Pumped-
Date
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: ° r
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
,___S.Wwart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler ;r Date /
Signature-of Receivina-Pa6itity Date
t5form4.doc•03/06 System Pumping Record>Page 1 of 1
Commonwealth of Massachusetts ,,rw
— pity/Town of Berth Andover »m« � ,�� �aEiVAe
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health ftr � atEl ut the
information must be substantially the same as that provided are-u fffg"thf fd` ', 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 System at
Ion:
p Location:
When filling out 1
forms on the
computer, use _ 4 ------- =------- ---only the tab key Address
to move your No.Andover _ — _ma_ --- 01845 _.
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:�. .,
Name
Address(if differen#from location)
State ----- Zip Code -----
Telephone Number
B. Pumping Record
1. Date of Pumping Date -- 2. Quantity Pumped: Gallons .. --
3. Type of system: ❑ Cesspool(s) 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:
Alcu
ame Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
(`-Stewart's Pre-treatmen Plant, 20 So. Mill Bradford, Ma 01835 --_ ---
—
signature of Haul
Date
Si nature o Rece n
---
g iving Facility -- Date--
t5form4.doc•03/06 System Pumping Record-Page 1 of 1
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omm nwealth 'of Massachus
ity/ToWn of NORTH ANDOVER] t
Y, t inRecord ,
Form 4
OEP has provided this form for use by local Boards of Health. The System Pumping Record mug
be submitted to the local Board of Health or other approving authority,
A,. Facility Information
Important:
t�e�o lin the
out 1. S t ocatlon: � � ......
computer,use ) t.
only the tab key A ss "
gy
to mono your
use th ret not Clty/Town State i
use the return p Gode
key... 2, S stpm Owner
Name
Address(It different from location)
Clty/Tvwn State Zip Cade
Telephone Number
. Pumping Record
1. Date of Pumping Date 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
tion of System',
xf
m Pumped By:
W
6, to„°. ..
qme Vehicle License Number
rcompany.. ; � �st� � Y�,
7, Locatlo where contents were disposed:
l Nff -
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r,•r DER.ha�provldod this tarm�for use by local Boards of Health, The $ysiem Pumping Record must
be subini46d to the local'Board of Health or other,approving authority,
1 :,r'•i '�i.� .,4� S SAY�' .,r,
A,. I PCIlity Inforl t�tlon
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,.:.ain r4arttt
unq out 9 System LocatJon'
only the tab key Address
to move your —
do not CI /town
the tritam �` tY State 7�p Code
�'p•n fir Jpy 1
•Yi.�. Ih\a N�a,��{I,I r lf' L'S System 4✓w Ir t.. I( '
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r
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Clty/TowrL State•
Z1 C.rGXdfi
4.
Telephone Number ---
Name
k, � u j Ord;:
p !� G{
�'I�ti f , 1•+W,.-.c�tIII,L,Y,�r L
9. Dato;of Pumping Date 2, Quantity Pumped; . . ----
Gallons
' 3r• ':Type pf system, Cesspo®i(s) eptic Tank ® Tight Tank
r ,. f
• � '�Qther(dasorib�),
Effluent Tee Fllt®�presunh,❑ Yes o If yes, was It cleaned? ❑ Yes ❑ No
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t5fonM,dw-Oa/Q r
;,. System Pumping Record Page 1 of t
Commonwealth of Massachusetts
? � City/Town of NORTH ANDOVER MASS E tr�n rr i n r ��ft
` Form 4 �
DEP has provided this farm for use by local Boards of Health. The System Pumping Record mu:
be submitted to the local Board of Health or other approving authority.
A. Facility Information - -- -- -----_-
Important;
When filling out 1, System Location:
forms on the
computer, use ---__. _._.__ __ _..,
only the tab keyr Address
cursor-do not r
r a
/Town
Cit -- --- _
use the return Y _...
Stake"
key.
2. S stem Owner;
Zip Coda
Y
Name -- - - ._ -
Address(if different from location) - -- -
State Zip Code
--._-.._._._ - _.__ ._-_.-.__._-,...__.
Telephone Number.. _ ..
Bumping Record __.---------
.,� 1. Date of Pumping _G , 2. Quantity Pumped: -- _�.
_..__
.F Gallons
3. Type of system: ❑ Cesspool(s) ❑ S. eptic Tank ❑ Tight Tank
❑
Other(describe): _..._____ ..._. _ _.
4, Effluent Tee Filter present? ❑ Yes ❑""No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Sy em Pumped By: ,
Hama �—�� ._._.
- - -
& Vehicle License Number
Company
7. Location where contents were disposed:
t ature of Hau Date http://www.massagov p/water/ provals/t5forms.htm#inspect
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t5form4.doc,06/03
System Pumping Record - Page 1 of I
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UA IYS'� �1
5 Y S4 t W✓�{ c
,A TT OF pUMPINO:
�» w. ....
QUA N7`�TY PL!M'f�Es�'>
l„ �__ Yf:
,'", I"VK� GN
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NVt..L U( i t_`01
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A __ �Af'3'l.EiS "?� Pt,.Ai
t�C CA KA YC>aYq
QTyeA EXPLAIN
g rW4 /
TOWN OF
SYSTE PUMPING
MAY ?-005
DATE: ...�� .
E-2vW,)OF HO:� f A N LX)I/F�','
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:
left front of house)o
�w
QUANTITY PUMPED : GALLONS
DATE OF PUMPING: . � -
CESSPOOL: NO _ YES -- SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FALL TO COVED - --
HEAVY GREASE BAFFLES IN PLACE
BOOTS LE ACHF JELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OT +R(E LAIN) ---
SYSTEM:PUMPE D BY. Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: .L. o® Lowell Waste
f
TOWN O ' NQRTN ANDOVEP,
UA!'h
//. ,.� SYSTE PUMPINQ RECOR-L,
SYSTtdM C�VVNFR ADDRESS SYSTEM LOCATION
DATE OF PU N /
���,.�,C..s �� ...�>. --.-QUANTITY PUMPED: . -.��'. '
_ ...._ ..
CLSS"L: r`O�_........ YES . _.. .. S00C 1'snk: NO, YES
NA rURE OF SERVI(,"B: Ft(UUTI.NE.,. _ � bMER0ENC;'1'
UESERVATIONS:
QOOD CONDITION PULL 'T.)COVER
"BAVY 0R-ASE BAMBS IN PLAC L
ROOTS LEACHMELD RUNBACK
6XCUSIVE SOLIDS .,. — FLOODED
SOLID CA YOVER, ....OTHER EXPLAIN
Syetvm Rum pod by
L'UMMHNTS,
CUN I ENT's T'KANSybRKb1) I'()
TOWN OF
li
SYSTEM I
DATE
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: :j_� QUANTITY h ELD : � ~" GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
—j—
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
MOOTS LEACI-IFIELD RUNBACK
EXCESSI + SOLIDS FLOODED
SOLIDS CARRYOVE R OTHE R(E LAID
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
0
.A,
r
CONTENTS SFE D T O: - <
'I +