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HomeMy WebLinkAboutSeptic Pumping Slip - 796 WINTER STREET 3/9/2016 Commonwealth of Massachusetts ❑ity/To wn of North Andover Sys, hem pumping Record Form 4 be used, but the DEP has provided this form for use by local Boards of Health. Other forms may information must be substantially the same as that provided here. Before using this form,.check with your Record must be submitted to local Board of Health to determine the form they use. The System Pumping , or other approving date in the local Board of Health authority within 14 days from the pumping accordance with 310 CM R 15.351 A. Facility information important When ffi 1 System Location: 1 forms ling out f on the computer, 7 9r, Zif-) use only the tab key to move your Address Ma 01886 cursor-do not North Andover State Zip Code use the return City/Town key, 2. System Owner-. -bra t :_6e_7 Name Address Of different from location) State Zip Code City[Town Telephone Number B. pumping Record ---------- - 415E 2. Quantity Pumped: Gallons 1. Date of Pumping Date 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): No 4. Effluent Tee Filter present? E] Yes ❑ Na ]fyes, was it cleahed? ❑ Yes ❑5. Condition of System: 6. System Pumped By: Vehicle License Number Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Date Signature of Hauler Signature of Receiving Facility ate System Pumping Record•Page t5form4.doc-03106 Commonwealth of Massaehusetks City/Town of North Andover o System Pumping Record Form 4 used, but the DEP has provided this form for use by local Boards of Health. Other forms may be information must be substantially the same as that provided here. Before using this form, check with your f Health to determine the form they use. The System Pumping Record.must be submitted to local Board o ng authority within 14 days from the pumping date in the local Board of Health or other approvi 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 Ma 01886 cursor-do not North Andover State Zip Code use the return key. _aliyfTown 2. System Owner: Name Address(if different from location} State zip Code City[Town Telephone Number B. Pumping Record l000 2. Quantity Pumped: -6-21ions 1. Date of Pumping _[Y ate 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): resent? El Yes ❑M No If.yes, was it cleaned? F� Yes ❑ No 4. Effluent Tee Filter p 5. Condition of System: 6. Systern*Pumped By: Vehicle License Number Name Stewart's Septic Service Company 7. Location where contents were disposed-. Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Date Signature of Hauler Signature of Receiving Facility Date System Pumping Record-Page t5form4.doo-03/06 Corrimonwealth of Massachusetts City/Town of No Andover System Pumplrig Record Form 4 DEP has provided this form for use by local Boards of Flea!th. Other forms may be used, but the information must be substantially the saffie, 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 accorclance with 310 CMR 15.1151. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 796 Winter St key to MOVe Your Address cursor-do not No Andover MA use the return key. cityrrown State Zip Code 2. Systern Owner: Drake Name even . .... ...... Address(it differont from location) -------------- tyfrown State Zip Code Telephone Number B. Pumping Record 1. Date Of Pumping Date 2. Quantity Pumped: il ons-1 ------------ 3. Type of systern: El (A-)sspool(s) Septic Tank Ej- 'right Tank L-1 Grease Trap F] Other(de3cribe): ........... ....... ...... 4. Effluent ee Filter present'? 0 Yes No If yes, was it cleaned? F] Yes L] No 5. Condition .. ...ystel U 6. Systert 1 3 ---------- -------- Name Vehicle License Number ,Stewart'` _SW.ic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01836 S" to ---------- 1 of Hauler Date ----------- Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of North Andover System in g Recor ❑� - 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, ��❑ y ° use only the tab 1 key to move your Address cursor-do not North Andover Ma 01845 use the return — — — key. City/Town State Zip Code 2. System Owner: �:Xci r Name mtum Address(if different from location) ----- --------- ........... ------ City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 1-- ba- 2. Quantity Pumped: - Date Gallons 3. Type of system: ❑ Cesspool(s) ZSeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): --- -- ................ I 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: Stewartseatment Plant, 20 So. Mill Br . /6 gnature of Haul Date J --------------- ---------------- 0 Id- 9 Signature of R ceiving Facility Date t5form4.doc•03/06 System Pumping Record-Page 1 of 1 I Commonwealth of Massachusetts REC E IVE _ i w City/Town of No. Andover System Pumping Record IJUL 18 2011 f mr4 Form 4 TOWN F N(RTG®1 ANDOVER 14EAL H DEPARTMENT 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 LocatlQr.L' �- forms on the -I . "m` - computer,use _ only the tab key Address to move your No.Andover Ma 01845 cursor-do not - --- - --------------------- use the return City/Town State Zip Code key. 2. System Owner:U11b( ✓� mo``'t ^ ... - -------- --------- ------------ Name - - ---- -------- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record (sh , 1. Date of Pumping `° 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 i 5. Condition of System: --- - 6. System Pumped E .__, -- / " -- - - — ame 44 ., Vehicle License Number Stewart's Septic Service Company — 7. Location where contents were disposed: S w rt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 e of au e V ate / C �" Signature of Receiving Facility Date t5form4.doc-03/06 System Pumping Record•Page 1 of 1 r ,CdMM6nwealti of Massachusetts �.� i � �^��'�� 'V 10 T'H AN V y f rn Ump!ng Record Form 4' DEP has provided this form for use by local Boards of Health, The System Pumping Record n be submitted to the local Board of Health or other approving authority, - A. F,aciiity information out , 9, Systeo tion: key A7 / got rn Cltyfrown Strata Zip Coda 2, em Owner me Address(if different from location) 1, City/Town State Zip Code Telephone Number i3. Pumping Record 1, Date of Pumping a 2, Quantity Pumped; Gallons`" 3, Type of system: . ❑ Cesspool(s) Septic Tank ❑ Tight Tank y� Other(describe): 4, Effluent Tee Filter present? ❑ Yes ❑ No If yes,`'was it cleaned? ❑ Yes ❑ No 5, Condition of System: Pumped By me Vehicle License Number �ce_ Company 7 Locatlo wher contents were disposed: L `�.� r¢..✓ ,� Ignat of Haufer Date , pass,gov/d.epAvater/approvalsA5forms;htm#Inspect {' %6/03 } System Pumping Record Page 1 of i f r r 1 it 73 1 1r f �P p IV MASS,,A C,,T-7 1 t PtQyldPd Wo to/t,.q ICl r o ^ DP I'vot1),11 IO lll1 Ipt'll 8 C to /tl C"t nVJlln OI C1110/ 1A�tO+lilCryl.�lnpil / l;d.'71 .. A. Facility In(orm�Uor 99 PqIo, , 1•Irl IY'I i,',�1 .'1�'r,1��sY Olin , v'��,1 �1�,''1 rti�1,�!�'I,�/1,'tl• 1�1,"v ,ill,,��ti u!I,i,';4 � �1 i '!'11'' 5u �� I i 1,1 1 Itlnl ram buuvnl / il,ipnpnl n',m011 ' Ilgr Pumping',.' 9111 r'1 I11�,1r •, ' .r r .' 14��/�111�',',' ' _. Eh1uo� rev ��(I` „1� form 7 �l y�(rr/,4 ,! t,/ Y0� h0 i Nj . '�rlui rt�11119r'ry'lilh U}iV/1'x'1"''' 4'tlSy Pvr�p00 1 171`11 tlr,'/ if, JGOnII N77. ",vlt , .•,r, ( w ,h� �'�`�i�{.,y1, J'�Z�(,i��LLi 1 ' rrI�)yyyyrr•'��y 1�r11 t�,...'"`"_"`" � � / l , `•�' �;�,�.;,' ''• � ,, rr./"1 '4P'I I, �l,�oplbnla,y�,o�q dl,�pos�o; 1i yl . /n1 ,Il is/ -ajl''111 , r , i It 1 1 , r St�n l„�I m�� ,�'nr ,porldop�ya(0ilbpproy�/ylblorm�.r;m,�an �Ilt 4�y S H(�S.. T7S 1 1� y 1 �� C�`/ y✓l d Al .r "„ P has provldad Lhl► iorrn for W.aa �,�,, . a© �u�rnl�loU la ltiv la�al L�� �ct)I �oa�Ce I 1 1 r "UIC Cl nr�p�((1 orGhyl � P'?�°I�, noiir A. Fac�llty info it t rl��n 1i E A L rF-�Ixi rnPa�r,i, )dx -- hwnI 0 1 0yl (GfT (OrJUQn) / 6,u at • oo,nJno r��mpp� -- ;S1',PumPin9 3, Type of oyolam; ❑ �as5paoi(s) o�.,� ❑''Thor (duchtof 4 Effluonl Too FUIa� - �,�1,1 y �` y05 s5 P maneo? y A GOnd jon'Q(SY� I 6 � SY @�1 Pvmpad 8y ,. 1 r:� w r v� i� YJ Y• 7' '.�' Voh G9 G9 j4 Pry(r 9l —. on wrnorQ corlenG�'were c""i,+r o soc coo ��-.'mow rnaas ;�ri�l�orlapprOV�Jal�blorm9 n1.m����y;oc� ___ 4 eddr Y�F{ '�o 1��r 4Y, 1 �� wy v.4 y`�+ t '".(1y,4f f�i \ 'l+6ili�/} ��kf +, ' r t., y1`It i f�S �tyly J��r/+ >�•. +i,'•• l'�t. l+rl .. J ��(J'q i Y � DEP has provided this farm far use by local Boards of Health. �P S stem Pumping Re ord must be subml ed to the local Board of Health or other approving u �� t w���nip O EF, A Facility Inforniation „ tin ortant, ,7 yvtien'pling out 1 System LoCatlan, foRns o'n the `. , uter,use � � . ) , only the tab key Address ,. y ) Lt to move our � ,�� cursor•do not CI /Town use the return �' State Zip Code ko� 2 System owner, r > Address(it different from location) 9P City/rown State ZJp Code Telephone Number umping z ;' • ate of Pumping oat 2, Quantity Pumped: ilons 3, Typo of ystem ❑ Cesspadl(s) Sptic Tank ❑ Tight Tank 'other(describe); 4, Effluent Tee Flit' presentT.❑ Yes, a' If yes, was it cleaned? ❑ Yes ❑ No , r , M� ..' ,...-, •r .a.. " 1 i,. 'i.Y t +S'r!.v. { �+. rt li�4.. . r' 6r SY err)Pump®d Name nVehicle Ucen*e Number -,4Q�}'►y'ry'�(�� {� r f t "Y • +.v� 4r''f�.� �� Ir4,r l,t �• �1 7, 'locatlorwher@ icont®nts yvere disposed: a of . fate http//wwwrmass gpv/dephtiater/approvals/t5fom�s,htm#inspect Wfomt4.doc•f36J03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of NORTH AN DOVE R,,,MASSAC H USMS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must 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 key Add—ress to move your cursor-do not use the return City/Town key. State Zip Code 2. System Owner: Name emm 'S Address(if different—from—ima—tiw—) -- City/Town State 0 MAY I 1 2006 Telephone 'I'OWN OF: I'k 4" ?'A/FJR B. Pumping te- 6 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [9, tic Tank Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ] No If yes, was it cleaned? F-1 Yes ❑ No 5. Condition of System: 6. System Pumped By: Name 4 Ve—hicle—bc—en—se-N—u m---ber Company jl/la'-VIX/2V 7. Location where contents were disposed: 6r Date Z, http://www.mass.go Signature of=Pprovals/t5forms.htmAnspect t5form4,doc•06/03 System Pumping Record•Page 1 of 1 i I J t "C)WN t > NORTH L) " /;a Y E�l1MP11*1r.i Y$r DKESS _.... � yr rUK� UN 9�;FtY1cTN.: NUV'(lt� qY �N1.7rrioIN FW.", K _,_�. L 6XC"$Y!'6 UUhlp� HFIt> 4P KUNi#At;�, r vDED ��'1 7 y�Wrrn f'"WTl}�ti<l �y �..,/�' iw."ti •�.' 7 � ' f .�. . ; 1 i .......... '17OWN Ol'i'NORIA-1 ANDOVJ-,,��,R, S"'I"EM PUMPING RJEWORI) DATE lqo YES ,,a�ivnc.'FANK NC) YE NATURE RdUll NI!,_ ()BS[��IRVAXKR,48, (3001)CONDITION FULL c owm, BA,fq'Lli,,S IN LACF, IXACHMBLD RCMRACK SOLID C',A R,RVOVEF�', (MHF,It EX I'LAIN SYSTEK4 PUMPIM BY V, COPOM L""'ll"ITS SYSTEM U PING . 1*51'LvAl OWNER eag ADDRESS ' I .• i (ex2mpled left frow of house) "41 iIATC, OF' PU PING: QU'A I'T'1�'Y U 1 P Ct 42 _.. ._ ,ALLO.,� YES SEPTIC TAIVX. N0 YES ATURE OF SERYICE; ROUTINE EMERGENCY US r. R VATIONS: i GOOD IYDITI FULL TO COVE.id HEAVY CREASE BAPI+LES IN PLA Ch.' ROOTS C'XCESSIVE LIDS FLOO Dg SOLIDS CARj1yOVXR ; 1° KR (EXPLAJN) , . C"U1*'I'.'yI ENTS; - Y