HomeMy WebLinkAboutSeptic Pumping Slip - 350 WILLOW STREET 3/9/2016 Commonwealth of Ma,-�sachusetts RECEIVED
Cltyffow s of Forth Andover
v° system Pumping Record TOW"
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
local Board of Health to determine the form they use. The System Pumping Record must be submit
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 �nformafion
Important When
Slling out forms 1. System Location:
on the computer,
use only the tab ) r ' 10
ke yto move your
Address
cursor-do not North Andover
usethe return ------..._.._.......... ........... ...... _.__.__.......__,,...,..__..... _..'
C /Town
key, �`l Y Stateri , Zip Code
2. System Owner:
Name
rE,ton
Address(if different from location)
City/T own State Zip Code
Telephone Number
B. Pumping Record
Date 1. Date of Pumping � 2. Quantit y Pum p ed: 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
Signature of Hauler pate
Signature of Receiving Facility - Date
tS om4.doc•03/06 System Pumping Record-Page 1
Commonwealth of Massachusetts RECEIVED
Cityffown of Nbr-Lh Andover
System Pumping Record
u'OWN Or-NOR1 ANDOVER
Form 4
HEAD rri DErMWEN1'
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
local Board of Health to determine the form they use. The System Pumping Record must be submi—ifte
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 �nformafion
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
use the return City/Town State Zip Code
key.
Z System Owner:
Name
anon Address(if different fror�To_c�tio�)_'
City/Town State Zip Code
Telephone Number
B. Pumping Rec*ord
4L.4 —
1. Date of Pumping 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [W 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 Syst
�Mv
6. System Pumped B -
Name Vehicle License Number
Stewart's Septic Service
Company
7, Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradf ord, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
,.5'1orm4.doc-03/06 System Pumping Record-Page 1
Commonwealth of Ma�>sachusetts
C--y/—i own of North Andover
system Pump�ng Record
Form 4
DEP has provided this form for use by local Boards of Health. Other farms may be used, but the
information must be substantially the same as that provided here, Before using this form, check V,
local Board of Health to determine the form they use. The System Pumping Record must be subn
the local Board of Health or other approving authority within JA days from the pumping date in
accordance with 310 CMR 15.351. RECEIVED
A. FacHity �nformation
important:When TOVV��OF�10r"T�l P�T_X)
ER
filling out forms 1 system Location: diEN Thi D&IN'UMEN"T
on the computer,
use only the tab
key to move your Address
cursor-do not North Andover —
Zip Code
use the return Sate,
u!
key.
2. System Owner.
1')6
'9"
Name
_Address(if—dr,ferent from location)
City own State Zip Code
fT
Teleohone Number
B. Pumping Record
2
1. Date of Pumping 2, Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ T ight Tank ❑ Grease-
Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was i-(cleaned? ❑ Yes L-] Nc
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
Signature of Hauler Date
Signature of Receiving Facility Date
,5form4,doc 03/06 system Pumping Record-
-
Commonwealth of Massachusetts
C y/oven own of North Andover
System Pump�ng 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. Be-Tore using this form, check\A
local Board of Health to determine the form they use. The Sys-Lem Pumping Record must be subn
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. FacHity Wormation
Important,`When J
filling out forms 1. System Location-.
on the computer, p TOWN OF I,�ORTH AJF)OVER
use only the tab HEALSH
key to move your Address - -----
cursor-do not
use the return North Andover
key. Ci�ty/Town State, , Zip Code
2. System Owner:
Address(if differ�ntfroWTo��t_io�) --------
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping /2. Quantity Pumped�
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank El T ight Tank ❑ Grease Tr
❑ lb�
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
iqn.ture of Hauler Date
i g�na t u r e Tof Receiving Fa_c i-I_�_(y Date
-. ........
t5form4.doc-03/06
Svstem Pumpinc Record-Pace
_ Commonwealth 01 Massachusetts
City/I own ®f North Andover
System Pump�ng 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 v,
local Board of Health to determine the form they use. The System Pumping Record must be subn
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Faci@ity Wormation KGOVED
Important:When M11 ��� ?
filling out forms 1. System Location:
on the computer, �,�. _ ,� "I ID VE
use only the tab
----
ey to move your Address
cursor-do not North Andover
usethe return ----_.._.._..... ._.... . ........ ;_\..._. __....._ ..._.-.
key. City/Town State Zip Code "
2. System Owner v
J" C:,.
Name
Address(if different from location)
City/T own State Zio Code
Telephone Number
B. Pumping. Record
.._ � .,.. ( ,.... GC ..,
1. Date of Pumping ---._.--- ---. �- 2. Quantity Pumped: - �=--
Date G21Ions
3, Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ T ight Tank ❑ Grease Tr
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
ame Vehicle License Number
Ste art's Septic Service
Company —..._.. .. ......_ .
7. Location where contents were disposed:
Stewark's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
ignature of Hauler
Signature of Receiving F acil'ry. _..,._,... ................ . . _
Date
5fom4.doc-03/06
Commonwealth of Massachusetts
City/Town of North Andover
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 wi
local Board of Health to determine the form they use. The System Pumping Record must be subm
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15,351.
A. FacHity an ormatgon
Important:When RECEIVED
filling out forms 1. System Location:
on the computer, _.�, C",
use only the tab ` �j(}{ (Vq, _
key to move your Address
cursor-do not North Andover 'WN rid 1 O� 'R C l l ANDOVER
use the re' — -----. 1EAUki DE AR NW-.wN h�
key. C'dy/Town Zip Code
2. Owner: a
� System
Ow { ,.
- —--= = -
Name —
re+
Address(if differentfrom location)
..--— _... --------.._.._._..—._......._._..
City/Town -�-—�
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - ( � -� 2. Quantity Pumped: >l .~ �
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ T ight Tank ❑ Grease Tri
❑ 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
SignatureofHauler —.__.._.,.,__...._-__—•- ---,_...__.._..
' Date
-----
Signature of Receiving Facility � ._ .-
Date ...._-._ -
i5form4.doc-03/06
System Pumoine Record-Pane
Commonwealth Of Massachusetts
❑i�y/Town Of North Andover
° system Pum Ong 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
local Board of Health to determine the form they use. The System Pumping Record must be submit`t
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 Wormation
Important:When RECEIVED
511ing outforms 1. System Location:
on the computer,
use only the tab ±. - t )t ( �.,,p „._...
r J .t
key to move your Address
cursor-do not North
use the return GPI.f .l`i i i.l i3O l V EN I'
key. City/Town __...._..._........ _.
y State, s Zip Code
2, System.-Owner: r,
c:� f
c
_._.. . __._. _..
Name --------
rewn
Address(if different from location) -•• ..._...._.. .__.___..-._._____.__..._-.._..__._.__.,_—,__
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping date .a '_...__.-. 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:
_Stewart's Septic Service Vehicle License Number
Company _..._...., ......._ .
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler — —.--..___....____-_.... _ D_._ate.....__..—._....
Signature of Receiving Facili#y " ""
Dale —°
t5forr14.doc-03/06
_ Commonwealth Of Massachusetts
City/ ®wn or North Andover
n stem Pump�ng 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
local Board of Health to determine the form they use. The System Pumping Record must be subn
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Faci@ity Wormation
Important:When
filling out forms 1. System Location:
on the computer, ,__, _. RECEIVED
use only the tab
key to move your Address
cursor-do not North Andover
use the return ER
,t !Tow
C' n ��
key. �y �_— _..._._...... ._ Tow 1,;
-–.
� AkP � �f4��i Zip Code
2. System Owner:
Name -
II�
Address(if different from location)
Cityrown State Zip Code
Telephone Number
B. PUMP ing Record
..,
1. Date of Pumping Da'4el �' -• ......_.. 2. Quantity Pumped: - )
Gallo s
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ ?ight Tank ❑ Grease Tr
❑ 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 T icens b"er
Stewart'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 Facilry
Date '
t5 orm4.doc•03/06
System Pumpinq Record-Pace
Commonwealth of Massachusetts
City/ I own of NbrLh Andover
system PumOng 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\A
local Board of Health to determine the form they use. The Sys-Lem Pumping Record must be subn
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 Wormation
Important:When
filling out forms 1. System Location-,
on the computer,
use only the tab
key to move your Address ... ......
cursor-do not
use the return North Andover -WED
City[Town RE(�4
key.
Zip Code
2. System Owner:
Name TOWN 0r-'
inn
Address(if different from location) ........ ......
State Zip Code
Telephone Number
Pumping Record
1. Z' Z., r .
Date of Pumping Da'te J6__ 2. Quantity Pumped:
Gallons
3. Type of system. ❑ Cesspool(s) ❑ Septic Tank ❑ T light Tank ❑ Grease Tr
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If Yes, was it cleaned? ❑ Yes ❑ No
5, Condition of System:
6, System Pumped By:
Stewart's Septic Service Vehicle License Number
6_o_mp_an_y--------
7, Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford_Ma 01835
_Signature of,�Hauler —
-
Date
Signature�cf Receiving i Dare
........
25'orm4.doc-03106
com,
monwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards 01 Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check u
local Board of Health to determine the form they Use. The System Pumping Record must be subn
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 Wormation
Important:When
filling out forms 1 System Location.
on the computer,
use only the tab ,
/U RECEIVED
key to move your Address LLL
cursor-do not 6
North Andover j
use the return �j
key. City/Town
. System Owner: Stage, F�NQRT1 O"" R Zip
2 6 P P Code
TOM
HENJ�1 DiH'AF4
Name -------
-
Address C,f different fr o mlocation)
City/Town
State Zip Code
B. Pump.ing Record Telephone Number
1. Date of Pumping
2, Quantity Pumped,
Date L Gallons/
3• Type of system: ❑ Cesspool(s) ❑ Septic Tank El light Tank Grease Tr
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System,
6. System Pumped By:
Stewart's Septic Service Vehicle License Number
Company
7, Location where contents were disposed:
..Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
SI
Signature ot Hauler
Date
"�ignature Tof
t5fOrM4.doc•03106
Commonwealth of Massachusetts
City/Town of North Andover
System PumOng 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
local Board of Health to determine the form they use, The System Pumping Record must be submiftLe
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facifity information
Important:When
RECEIVED
,illing out forms 1 System Location:
on the computer, 0 I
use only the tab
key to move your (J J,
Address
cursor-do not
use the return North Andover TOWN OF�,�ORTH/�,�,,�nCVER
key,
2. System Owner: Zip Code
Name
Address(if—diffecent from l_ocatjon)'
Zip
Number
B. Pumping Record
1. Date of Pumping -6a—tj,2- 2 5 2, Quantity Pumped:
Gallons ---
3. Type of system: ❑ CeSSPOOI(S) ❑ Septic Tank ❑ Tight Tank El 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:
Stewart's Septic Service Vehicle License Number
Company
7 Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
- Date
ignature�of Receiving Date
,5',Orm4.doc-03/06