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Home My WebLink AboutSeptic Pumping Slip - 259 GRANVILLE LANE 3/8/2016 Commonwealth Of Massachusetts City/Town ®f ti -Arde)ve r a� System in Record Form 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 y p a°,o filling out forms 1. Syst Lo ��,: r G on the computer, use only the tab key to move your Add ss cursor-do not Gob use the return key. City/Town ___ Moe Zip Code 2. System Owner: tab Name atwn Address(if different from location) ----- -- --.. City/Town State Zip Code Telephone Number B. Pumping c®r 1. Date of Pumping - — 2. Quantity Pumped: _ __50--- —.._._.._._.....-...----- 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 System: 6. Sy tem um ed B Vehicle License Number ` ewart's Septic 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 t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts' Cityffown of No Andover System u in d 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 asee computer,t 1. S stem Location: � g y Y try °t key to move your Address cursor-do not No Andover use the return __ _._ Ma key. City/Town State Zip Code -- 2. System Owner: Name reunn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record i ([ _ 1. Date of Pumping Date t M. a. 2. Quantity Pumped: �` 1 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 System: f... 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location'wher'I contents were disposed: St wart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01635 Sig nat,uue°''&Hauler'°° Date . .._... Signature of Receiving Facility Date t5form4.doc°03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of N®. Andover System in 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 Information Important:When filling out forms 1. System Location on the computer, use only the tab – key to move your Address cursor-do not No. Andover Ma use the return --- -------- St -- City/Town State Zip Code key. 2. System Owner: ern.( '� I��y� �� , C ",u --- f - ( � Name E,Yk�1 C7 � � - emm ----- - -- -- ----- -- - Address(if different from location) ,. Ii�i.rF�B,P�i k.bl.f'l`Jrll�il l^fi! City/Town State Zip Code Telephone Number B. Pumping Record f #-6 1. Date of Pumping Date- 2. Quantity Pumped: - te Gallons 3. Type of system: ❑ Cesspool(s) °Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): ------- --- - - -- -------- — 4. Effluent Tee Filter present? Ct Yes ❑ No If yes, was it cleaned? [Yes ❑ No 5. Condition of System: 6. Sys e M fed Name �`� Vehicle License Number Stewart's Septic Service — Company 7. Location where contents were disposed: Stewart's Pre-tn"-tm t Plant, 20 So. MITI Bradford, Ma 01835 Signa re o L ler Date Signat iving Facility Date – — t5form4.docc 03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of North Andover F. 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 Information Important:When filling out forms 1. System Location* on the computer, use only the tab key to move your Address cursor-do not North Andover Ma use the return -------- key. City[Town State Zip Code 2. System Owner: . Name e wn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping ec®rd 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other (describe): - 'V-1_k_)1) � . 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 ------------ - -- tutsfTM+alr° -.. .. ... Date na f' - ilil __.._._._.,.. ....__. .M Date 9 9 Y t5form4.doc•03/06 System Pumping Record•Page 1 of 1 n Commonwealth of Massachusetts j City/Town of North Andover � M - System rd � r 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 forms 1. System Location: r on the Computer, °" " w. ..� ) use only the tab .� �. w1 key to move your Address cursor-do not North Andover Ma use the return -- -- key. City/Town State Zip Code 2. System Owner: .. , tab � �� —• t s� W .. Name rerwn Address(if different from location) City/Town State Zip Code —.._. Telephone Number B. Pumping ecor 1. Date of Pumping ;bat 2. Quantity Pumped: 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 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 __.w__._Sign e of Hauler "" - . .. Date _...d. ----- ------ ignatur of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1