HomeMy WebLinkAboutSeptic Pumping Slip - 227 GRANVILLE LANE 3/7/2016 RECEIVEF
City/Town of 1\10. ANDOVER
System Pumping
Form 4
pft AL 1
DEP has provided this form for use by local 13oards of Health. Other forrns may be used, but the
information must be substantially the same as that provided Mere. Before usinfl this foram, check with your
local Board of Health to determine the form they use. °1'`he C3ystenr Pumping Record must be SUbmitted to
the local Board of Health or other approvirttl authority within '14 clays from the purrtpincl date in
accordance with 310 C;M1 '1 5.;3 ,1.
A. Facility Information
Important:
When filling out 1. System Location:
fonars on the
computer,use x27 - LANE.__...
-
only the tab key Address
to move your NO. ANDOVER MFG 01 84.5
Cursor-do not _- _
use tkae return Cityrrown State Tip Corte
key. ...__ 2. Caystern Owner:
r'Iret,
JAKE CHAC E
Naamo
--- ---..... .......____— ....__.- --.__.. ......... .__ ....._ .. -... __.__.... _.___-_
(ienarrr Address(if different from location)
City/Town state Zips Crack,
_......... ......................_...._ .... -- —-_
Telephone Nunber
_.-_-...... _...... . _ _ _...,-_-- .. .............. ------------_....-. _......................_ .............. ...................
Pumping Record
1. D n3
1/�Jl Date of Puntp /29/1 mate . C uaantil CpCt
Pumped:umpe : Gattor,:,
. Type of system: --_.l esslaool(�!,) e.f�ttic faart4� [ Ticttlt Tank C � Gre,aase"fraap
(_] Other(desci ibe):
4, Effluent Tee Filter present? Yes �..� No If yes,was it cleaned? f Yes Ej No
5. Condition of System:
.....
C. System l un,tped By:
JAMES Id. CURRIER -- - ..... _-----
Naame Vehicle License Number
J's SEPTIC & DRAIN
Company
7. Location where contents were disposed:
G1.SD
5inalure'of p°larder pate
signature of Receiving Facility Date
t5fouaaxt.doa;«03/06 13yafern f'urnping Record- r'age 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER
- -_ System Pumping
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 hG 'i T' d t i11
accordance with 310 CMR '15.351.
A. Facility Information �r
l� i
Important:
When filling out 1. SyStern Location:
forms on the
computer,use 227 GRANDVILLE
--- --------
only the tats key Address -
to move your NORTH ANDOVER MA 0'1845
cursor-do not -----..._... - -- -...._.._...__.... —---
use the return City/Town State Zip Code
key.
G. System Owner
JAKE CHACE
Name — -- -.- _ —
- — ------
Addrree ss(if different from looation)
City/Town State Zip Code
—- -
----- - ----- ------------------
Telephone Number
B. Pumping Record
r
1. Date of Pum a ping 3 — 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 Systern:
GOOD CONDITION
6. System Purnped By:
JAMES H. CURRIER H79 406
Name Vehicle License Number
J's SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
8/5/13
Signature of Hauler Date
- - -- ------ ---- - ......._ - ---..
Signature of Receiving Facility Date
t5form4.doc•03/06 Systern Pumping Record• Page 1 of 1
Commonwealth of Massachtisetts
w City/Town of No Andover
System in coy
4ry� 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 hers-f efpr� y '$ this corm, check with your
local Board of Health to determine the form they use. The,'System' umpingRecord 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 15351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab � ❑ in ul l e�
key to move your Address —
cursor-do not No Andover
use the return Ma
key. City/Town State Zip Code
2. System Owner:
Name —
Address(if different from location)
CityTTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date C? 2. Quantity Pumped: —
Gallons
3. Type of system: ❑ Cesspool(s) [_A_'11 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. Syste), umped By:
Name Vehicle License Number
Stewa eptic Service
Company
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
t5farm4.doc 03/06 System Pumping Record•Page 1 of 1
Commonwealth ®f Massachusetts
City/Town of . ANDOVER
Pumping System r
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:
forms on the
computer,use 227 G_RANVILLE LANE
only the tab key Address
to move your NO. ANDOVER MA 01645
cursor-do not City/Town State Zip Code
use the return
key. 2 System Owner:
r� JAKE CHACE
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ec f
1. Date of Pumping 9/2 — 2. Quantity Pum 1500
Date 1/12 Pumped: 1500
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:
JAMES H. CURRIER _ H79 406
Name Vehicle License Number
J's SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
9/-21/1--2
Signa re;of Hauler — _ --- Date
Signature of Receiving Facility Date
t5forn4.doc-03/06 System Pumping Record• Page 1 of 1
Cornmoriweal-th of MassaChUseltts ,l ,
Cityffowri of NO. ANDOVER
System Pumping Record
� i C';�'Pr4 r �!f r ir6r'likxOb�A�'i'`
rt" 9 4 rs (} l C Ye P
.,��1 ,ee....i, mou,..n.. ✓nmmnwvM rn �u1
DEP has provided this form for use by local Boards of h°leealth. Other forms may be used, but the
information must be substantially the same as that provided here. 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.
A. Facility Infonnation
Important:
When filling out 1. System Location:
forms on the
computer,use 227 G ANVILLE LANE
--- -- --- - ------.....___-
only the tab key Address
to move your NO. ANDOVER MA 01 845
or-do not
use the returr7 City/Town State Lip Code
use
key. 2. Syst.ern Owner:
Name
JAKE CHASE
are Address(if different from location)
_...
City/Town State ,Zip Code
Telephone.IVurnbei
B. Pumping
/6a/11 1 875
1. Crate of Pumping - - __..._ _ _ 2. Quantity Pumped: - ---
crate Gallons
3. Type of system: El cesspool(s) Septic'Tank El 'Tight "rank
[� Other' (describe):
4. Effluent Tee Filter present? [WY es El No If yes, was it cleaned? es ❑ No
. Condition of System:
C. System Pumped Sy:
James 11. Currier H79 406
Name Vehicle License Number
J's Septic& Drain
company
7. Location where contents were disposed:
GLSD
L 9/0/11
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record>Page 1 of 1
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SY slem P umpinq Rocom Pago i . .
.. �,,,., .
_ C ity/Town of, DOVE,. �7 E
a System Purn'ping Record
� ,
Form 4
I �
P has provided this form for use by local Boards of Health. The System Pumping Record rrlust
be submitted to the local Board of Wealth or gather approving authority,
. Facility Information
Important:
When tilling nut 1. ystern Location: ,
fortes on the
Computer,use ( �
only the tab key Address
to MOVe our p
c;ursar da not (
use the return Cityfrown Mate Zip Code:
key.
�� ;?
- . Syster Owner:'TOwner:
r`
n, tab
_ _...__ ._____ ____._. _. _.__-.. _...___
Name
..._....
Address(if different from location)
City/Town Mate Gip Cade
..............._ _... ._ ._..... _..
"telephone Number
B. Pumping r
1. Date of Pumping Dat ✓ --- 2. Quantity Purnped: Gauans
3. Type of system: E Cesspool(s) Septic Tank El Tight Tank
Other(describe): __ _...._.___ . ---. _ __-__-.
4. Effluent Tee Filter present? [� Yes El No if Yes, was it HP Irle�d? Yes No
5. Condition of Systerm
6. S y f�em Purnped Gay
1'1 d11)rl'1,')
IVarr7o Vehicle License Numb(-r
Company
cart v pp
- r . --u
7. Location where contents were disposed:
' aN
Signature at Hauler Date
http://www.rrinss,gov/dep/water/approv is/t5forms.htryAnspect
t1jforro4.doca 06/03 Systern Purnping Record >Page 1 of 1