HomeMy WebLinkAboutSeptic Pumping Slip - 94 GRANVILLE LANE 3/7/2016 '�L , Commonwealth of Massachusetts
City/Town of
System in cr NORTH
=y 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 forme t filling out 1. Syst�LoCaY .��� �I'�t
Ion: 8
computer,use V
only the tab key Address to move your
cursor-do not --—
t
use the return City/Town State Zip Code
key. 2, System Owner:
rf
Nam
-----------
e ---- —
° Address(if different from location)
Cit (town — ------- --- --
y -------- - State Zip Code
VTep'ho'
ne Number
B. Pumping Record
1. Date of Pumping . tt 2. Quantity Pumped;
Date Gallons
3. Type of system: ❑ Cesspool(s) O.Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yep "No If yes, was it cleaned? ❑ Yes -No
5. Condition of SysAem:
6. System Pumped By:
er1
— —----- —
Vehicle License ��*b, — ---
7. Location where contents were disposed:
�w
�— —
Signature of Flauler —_-- ---� r
Dated
Signature of Receiving Facility _ Date —
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
t CftyfTown of
System Pumping Record NORTH AtNDOV
Form 4 0
DEP has provided this form for use by local Boards of Health,Other form.:n)a be used,but the
nformation must be substantially the same as that provided here.Before usin" t ) farm,check with your
local Board of Health to determine the form they use The Syste; g,'rk°v f"rkL
tiros local Board of Health or other approving authority within 14 days fram themiWdr�4aVdT$��l 1'Lf6 f f C f 4
accordance with 310 CMR 16.351
A. Facility Information
Important: .
When filling out 1 System Location. ffryry
kerns on the Y._- �
compulef,use ,_ `P'"�€:r,^'h t,f.,
W
only 1he lab
u5q,the mo era fort A �ess
I" yfTow+r U`3(alc 7,p C.rad4
hvy 2 S,ylslem Owner
name
f"-`- Address Of ddlcrem from localioro
Clyf own Tel;lilt { Z 1 l oaf.
4 y ��, lr � r... f
1 ..ti �)
le,
Number
B. Pumping Record
1 Date of Pumping D,ite' i 2 Quantity Purnped Gallons_
Y
3_ Type of system [_] Cesspool(s) Septic Tank .� Tight Tint j_J Grease Tr;afr
(_) Other(describe)
A Effluent 1-ee Filter present? �_] Yes C NI•-No if yes,was d cleaned? (_ Yes ("I_No
5. Condition of System,/ '
6 System Pumped By
N�amv p WPhu,lr t.,lren^.e rdumrrer
Gompany
7 Location where
���� �caontentss were disposed
.
firth Andover, M A
SIC
rnature or Hauler t7 rfte
Signalure of Receiving faculty 0.fhJ
151orm4.Uoc•03106 System il"(T,p,fvj Record^Flig"t or f
commonwealth monIr ealth of Massachusetts Form 4 – System Pumping Record
Massachusetts
system Purnping Record
System(7wner t,,,+ d k
rOWN EHEM:m DEPARTME
F rMn N MCCIV R
Type;
Emergency routine
Yes laBYti�Cdan6L; ll(> N "✓
Cesspool; No septic-
_-..
Gate of pumping: y puml��e��,/—l520. Galloh,5
stem Pumped By: Wind River Environmental,LL.0 permit .................___........._.......
....._.....__._... ...._..__..._....._.............
Contents-Transferred to;
Contents Disposed at:
Dcrhe; _.._ _ �._.� _. _..._-._...__. pumper Signafure� ------- Ix .
Conditionof System/Other Comments _._ ..._........._ .._..---.._._ __..___.._.......__._....._...__........__...._..__.._.....__....._._.__...__........__....__._.__....____......_......_..___............__._........................_.__..._.....
Dep Approved Forra. 12/07/95
¢'rinl<s�i an iu°°���aed pnr'acr
Commonwealth Of Massachusetts " M� WWU
City/Town cf
a, Y t u i r f�EK
Form 4 TOWN OF V��u RTH ANDD Fft
'titi HE °u� D �f� °� r
DEP has provided this form for use by local Boards of Health. Other fo Mt"ay e ;4bw�f 4a,
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 q G V t � }
computer,use —" 1 ---- --- __._..-------_
only the tab key Address / ` /( ,
to move your I�Ct7 °��1 I" Ct C14 ✓ -- 1 ! —_ — —.__ __
— —
cursor-do not -- — — — -- — State Zip Code
use the return CilyrFown
key. 2. System Owner:
rp � CaC �DC"( 1t`�0VI
Name
^pro Address(if different from location)
--
City/Town Stale rr � Zip o e
Telephone Number _
Pumping Record
� µ ----� -- 2. Quantit Pum ed:
1. Date of Pumping Date y p Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe); --_—__ __/
4. Effluent Tee Filter present? ❑ Yes Imo' No If yes, was it cleaned? ❑ Yes �No
5. Condition of System:
& System Pumped By: _
�-�, �� (A0 Vehicle License N� �
-— umber
Name
_\41YlC — iJ � _fl�I—C "olC'11° Gt
Company
7. Location where contents were disposed: A
___ __ _____ — --.._ — - -------- --—
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
— City/Mown of
a
System pin oor� .
Form 4
DEP has provided this form for se by local Boards o 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: p1,A11, .,,, ?00
computer,n t use t 1. System Location:
forms on the �. �� � � f�"��°Wf"jai �
filling �G ur P�d'�h�f t�h ANDOVER�
only the tab key Address
to move your s
cursor-do not f"` ,-,•�. ,c.����,....
use the return City/Town State Zip Code
key. Z System Owner:
Name
n Address(if different from location)
City/Town State Zip Code
.. Mwa ")J 411
Telephone Number
B. Pumping Record
Date 4 n,<:w"f y Pumped: Galls
1. Date of Pumping 2. Quantit
3. Type of system: ❑ Cesspool(s) [TSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D' No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped v:
V rt �,.� �
Name Vehicle License Number
Company
7. Location where contents were disposed:
L.S.D. _
Signature of Hauj,ep'. �pss Date
Signature of Receiving Facility Date
t5form4.doc•03/06' System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
City/Mown of NORTH ANDOVER, M AS HUB TT m.,
-
System Pumping Record
Form 4 ,
DEP has provided this form for use by local Boards of Health The System Pumping P cord must
be submitted to the local Board of Health or other approving uthprif
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
Name —
Address(if different fro location)
City/Town State _ Zip Code
Telephone Number
B. Pumping Record
- . �.'C;e
1. Date of Pumping Date 2.`�Quantity Pumped: Gallo
3. Type of system: El Cesspool(s) ED Septic Tank ❑ Tight Tank
❑ Other (describe): — --- —
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
r
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
Commonwealth of Massachusetts Form 4 system Pumping Record
Masscachuseffs
System Pumping Record .......
......................... J U Ni
rstem'Owno-r System Location
TOM,i OF
..............
)e. Emerge tic
Routine
;$pool: No ......... Septic Tark No I",--I Yes E!fl
he of Pumping: '7
Quantity Puniped:.1_5 Gallons
;tenn Pumped Ry: Wind River Environmental,LLB Permit#:
-------..... .......
tents Transferred tw
..................... ................... ............................... ............................. .............................................. ..................... .......... ........ ............
.........--------------- ............. -----------............... ................... ...... . .............--—-------
tents Disposed ot�
............ ............. ...............
....................... --—-------------------- .......... ... .......................... ........
-I-Iolle
e: ...... PLImper Siqnatut'e: ........... ...................
jw-
difion of System/Other Comments .......... __............................_,_..e.._....._
................ ................. .................. .............................. ..........
............ .......................... ................ .............. .............
.............. ........ ------------- .............................. .............-------
..................---..-I..................... --------- ...... ...........................1------..I---.-------- ............
.....--------1--........-I.,.................... ........ ....................-.1-1--l"......."............ ..........-..............
bep Approved Form--12/07'/95
Farrar 4 -- System f aa�a d
r�crarraaarsra+sa th of ssachusatss "w
u�wmww
ssachwei ts
,ysOwrw1a�abm �^ CIS
System Owner iystaro Location
MAY I
I
o �p
r C'4
Y r
1 /
imiwwwmwwiwmwwwwmumm uwwwwwmwwmmmmmwwwuu mwwwuraamuw wm uuwmmiwummmmmwmmmmm Eq T'yp'e: Vaasa apssy Ataaastlnms Cass l; I .w "yeas Septic tank: Pia `Oes
bate of Pum in Y� Quantity Pumped; —L4&--O Gallons p ', m w t m �m�
system,pumped y: �GVd�ry amsr ar�dasxas a�r�aP � � m �w � Permit s
Contents tr ansfar and W
,����� �mswmmumm�wo wwuwwwwawwa�w m��w�www,��w�w�wmwww,wwww��wwwwww�wmm�ww mwwm�mwwwwowww�
Contents Disposed at:
mm�wm���wawmmwmmwwmuwW�mww o��w�wwwwwwwm �ww m w��� '` mw �� �- t. �, ww�ww„ e
bate; Frsrnper , nature.=
Camaeiitian Of*system/Other"`earn 'rats
Cyep Approved Form - 12/07/95
Fcs^wr'r 4 _.. System Pumping Record
Conurionwealth of Akassachusetss
ssactw tts f' ECG
H
t air f t ,._,._ '
a
JUI
1_
System cwnw tam Location TH DEPARTMENT
Typs: rrrr4WyP daa'tfrro
Zt",pal:
�f Parnpbwtq:
System Pumped By wind Riv °EnvilwMental, !f c Parmit
Contents tw ons to:
Cooftnts Disposed at:
Date: Pumpar f tum: m
Condition of ystetn/;7tt r^Comments
bep Approved Form - 12/07/95
r'
rorna 4 ,. System PumplrrR,Record
Cosnnuonw altia of Mossaciaasetss
Massachusetts
." storm @Yard aiq ptrdC
System Owner System Location
l
mawwenaiww mswmt .. wn..
Type: Emerogency Routine
Cess al: Ni. yes w
Septic tank: P^Ju yas E"
bate of Pumping: �, ���� Quantity Pumd d: Gallons
System Pumped By. l^ Ind Piw-r Errviivanaerrtu/, UC Permit
Contents traansfen,ed to:
Contoni-s Disposed at:
a
a
Cate: Pumper Signature: "
Condition of System/Ofhar Comments
b y Approved F - 1210719
Forwa 4, .... System Paaas phwj kecow,d
ConvwnweaWi of Mossachusetss w Sf �y�li',6�t 4,, „
Massachusetts
r,.
aJ
r,
System System Location
Type: nasrr nary Ftcwtrtirr�
Cesspool: N o 'yes is tank: Per yeas
w Pt a
Date of Pumpivgz Quantity Pumped: ai4ans
System Pumped By: wM ftivelf.F'trvhvfi ntd1, UC Permit
C(mt nts traansf tai:
Contents Disposed cat:
Date: .. Pumper Signature:
Cowition of Systetwot1wr Comments
Des ADrrrov d Farm - 12/07/95
Form 4 -" System Pumpiaag Record
Comaan wweah°h of Massachusetss
Massachusetts
vstena Pumodrra
�'f
System Oww System Location
Type: Emergency amine
Ce N: No ,� Yes Septic tank: w Yes 1
bate of Pumping: 5 Quantity Pumped; C� +- Gallons
System Pumped By: Wind a?lvasr EnvIronawntal, Lie Permit
Contents transferred to:
Contents bisposed at:
bate:
adi n of System/Other Co"Unents
bep ,Approved Form - 12/07/95
Form 4 ... System Pump4nq Record '
Massachusetts
ysLtaym_Pra u d".Aecord
/I
i /��
(J
1"y Erwrracy � Nts�te�tir
Cesspool: PJa Yes w
Septic tank: f°�ka
mate of Pumpin : _ C U Quantity Pumped: Gallons
Sys*,m Pumped By: bow River Efivimn6wntal, Lie Parwaait
Contents irarasfe d to:
E'ast Fitchburg
Contents bispo: d at: Waste Water l nt,
r r
Date: Pumper, iynaatur^e:'.
Condition of Systent/Other Comments
bep Approved Form - 12/07/95
Form 4 System Pumping Record
Commonwealth of Mossachusetss
: Mossacivisetts
System Owner System Location
J=l JO Hj, I
4
Type: Errgarrocy Routine E4
Cesspool: No Yes Septic tank: w Oye,
Cate of Pumping: l Quantity Pumped: 0 0 cl Gallons
-
System Pumped By: wfini ftivem Environowntal, UC Permit
Contents transferred to:
Contents b1sposed at:
Date. I 0 Pumper Signature:
Condition of System/Other Comments
Dep Approved From - 12107195 rw
Form 4 -- System Pumping Record
ConvnonwealA of Mossachus tss
Massachusetts
a st,km to ri R ecord
System Owner System Location
1°ypo: Cm r ncy Routine ..,.
Cesspool: per, Yes Septic tank: W OYOS „m
Date of Pumping: �. ���"" ,r � o Quantity pumped; 3°L, Gallons
System bumped y; Wind Riven Snpironmental, [ e permit
Contents transferred to.
Contents Disposed at: ry
fW2&1—a4a:
Pumper Signature
Condition of System/Other Coma tents
FORM 4 - SYSTEM PUMPING RECORD
CURRIER
SEPTIC & D Ili SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978) 774-2772
COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNER: SYSTEM LOCATION:
� ? ck _
DATE OF PUMPING: , -. ''NUANTITY PUMPED: C" GALLONS
CESSPOOL: NO F7 YES F-1 SEPTIC TANK: NO 0 YES
SYSTEM PUMPED BY: CURRIER SEPTIC c& DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE: INSPECTOR: cr-
FORM 4- SYSTEM PUMPING RECORD
CURRIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978) 774-2772
COMMONWEALT OF MASSACHUSETTS
MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNE SYSTEM LOCATION:
DATE OF PUMPING: / ANTITY PUMPED: GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO 0 YES JZ
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO: S
1
DATE: ` I INSPECTOR:
J