HomeMy WebLinkAboutSeptic Pumping Slip - 1459 TURNPIKE STREET 3/9/2016 Commonwealth of Massachusetts
- u City/Town of NORTH ANDOVER
System Pumping c 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 uE.0 E I V E D
filling out forms 1. System Location:
on the computer, ML11,, 20
use only the tab 1459 TURNPIKE STREET
key to move your Address °b"OWN OF �,R DM'
cursor-do not NORTH ANDOVER — MA d�
— -- E��01f'-$4 ;"I' g
use the return City/Town State Zip Code
key.
2. System Owner:
(� KEVIN DUBE
Name
renrn
----------- — ------- -------- ------
Address(if different from location)
------ ----------- ----
City/Town State Zip Code
Telephone Number
B. Pumping ec®r
1. Date of Pumping 7/7/15 — — 2, Quantity Pumped: 1000
Date Gallons
3. Component: ❑ 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. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAMES H CURRIER II H79 406
Name Vehicle License Number
J' SEPTIC & DRAIN
Company --
7. Location where contents were disposed:
GLSD
7/7/15
Signature'of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
I(„n
Cornmortwealth of assachuseft
r- d-lyffown of NORTH ANDOVER
-nping Record
q
l'1lrUr(r I f 1
a 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 the 1459 TURNPIKE computer,use -- -------------- --- -only the tab key Address
to move your NORTH ANDOVER MA 01845
cursor-do not City/T --..
Town State Zip Code
use the return
key. 2. ,System Owner:
Name
reran ` AddIress(if different from location)
---St--ate Zip--Codde e ------ . —
City/Town
Telephone Number
B. Pumping gar
7130/13 1200
1. Date of Pumping — ___ __—_._-.—_._-- 2. Quantity Pumped:
Dace fe 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:
GOOD CONDITION _-- --_. -----------
6. System PurTlped By:
JAMB_ S H. CURRIER H79 406
Name vehicle License Number
J's SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD —
"�� �.� 7/30/13
Signature of Hauler Gate
--- — — —... ----- — —._ .. — ....... —_.---....._ ---- —
Signature of Receiving Facility Date
t5fonM.doc-03/06 System pumping Record- Page 1 of 1
Cwnaionwealth of Massachusetts
Cityffowii of NO. ANDOVER
- �;1 Record
i' 4: arm 4
DEP has provided this form for rise by local Boards of Health. Other fornas may be used, but the
irrfarmation must Sao substantially the some as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The Sy Wry tae submitted to
the local Board of Health or other approving authority.
--.-Facility �" �. �
Important:
When filling out 1. System Location: t'` a t°r
forlTls on the
computer,use 1459 TURNPIKE ST.
only the tab key Address
to move your NO. ANDOVER MA 01845
cursor-do not ....... — __.. ..._..... ........... ...........
use the return City/Town State Zip Code
key. . System Owner:
Name
JENNIFER DUBS _
nrun, Address(if different from location)
City/Town State Zip Code
TcPel`rttone f4un°rber
B. Purnping Record
1. Date of C urnping 6/ /11- -- 2. Quantity Pum 1200 ped:
Date Gallon";
3. "type of system: U cesspool(s) Septic;Tank ❑ Tight Tank
(❑ Other(describe).
4. Effluent Tee Filter present? Yes L9/`No If yes, was it cleaned? [.I Yes U No
5. Condition of System:
G. Systerrr Pumped y:
Jarraes 9.1. Currier H?g 406
Name Vehicle License Number
J's Septic& Drain
Company
T Location where contents were disposed:
GLSD
4_4 t Ea/x/'91
Signahg of Mauler Date
tt5fonn4.doc"O6/03 System Pumping Record>Page 1 of 1
91 - ' amCity/Town of ANDOVER � ���
_ 44
A.:
Form
...
DEP has provided this form for use by local Boards of Health. O �,. a �� �.. t 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.
A. Facility Information
Important:
When filling out 1. System Location:
forms the 1459 TURNPIKE ST.
computer,use _ .. -- _----- -—
only the tar?key Address
to move your NO. 0)1
ANDOVER MA $45
cursor-do not __ __.. -- _ _— .........— _.._.._.— _
use the return Cit y/Town state Zip Code
key. 2. System Owner:
KEVIN DUBE —
Name
- — - --._ -------- --_ ---- -
�" Address(if different from location)
—--- .._.. -
City/Town state Zip Code
Telephone Number
B. Pumping gar
1. Date of Pumping __ —... 2. Quantity Pumped: 1200
Date Gallons oGallons
—
e f
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No It yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Benjamin Shute H79 406
Name Vehicle License Number
J's Septic& Drain
Company
7. Location where contents were disposed:
GLSD
6/3/08
atur f Mauler Date
f
t5form4.doc>06/03 system Pumping Record•Page 1 of 1
It Massachusetts p g q�^�'y q" p ���
' k.,wd& 9 6�� 4,.��Qom& �,,°"� � � � I
d f o.f
City/Towri of NO. ANDOVER
i
System i ;I) `;4 , 4a .I
DEP has {provided this form for rise by local Boards of Health. Other orr°��r� I .. ..��� ,�liu�th
information must be Substantially the sarne as that. provided here. efore using this form, check with your
local Board of Health to determine the form they use. The System PUr iping Record rrtust 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 '14,59 TURNPIKE ST.
GOIYIpUter',Use, __ - -- —
only the,tab key Address
to move your NC?, / NCJCJVI°° MA 01545
_._
— __ Zip Code
cursor-do not —_ _ __ — - --- — -- State r
use the return City/Town i
I
key. Z system wrier:
r . JENNIFER DUBS —...
Narne
erE n Address(if different from location)
Cilylp-owra state Zip Corte
_ _.. ..........
Telephone phone NurrYber-
B. Pumping Record
6/14/07 1 000
Z. Quantity Pumped: _ -
1. Cate of I�un-IpirttT _ __ __ y 1 � (.aailor,s
Date
3. Type of system: Cesspool(s) (� �:�e�tic"fartk �� Tight Tank
I Other(describe): -
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleanest? Yes No
5. Condition of System:
.....__--..-.
6. System Pumped icy:
Benjamin Cftute 1179 406
-----
Name Vehicle t.0:;e,nse Nurrrber
J's Septic& Chain
—_.—
Company
7. Location where contents were disposed:
GLS -- — _
� 6/14/07
.e, I tauter Date,
t5forinz4.docn 06P03
syStOrn PUInping Record•Page 1 of 1
Commonweidth of Massachuset6
Massachusetts
-ystem ccr ystem �sr 4n
kJc'), 0
Type: Emergency ❑ Routine El—"-
Cesspool: No m... Yes ❑ Septic Tank: No El Yes
Date of pumping `: / ..
Quantity pumped: gallons
System pumped by (Company)- ( j ) Permit
Contents transferred to:
.Contents disposed at:
Date M � ( :. p per Signature ,
c, ° ,? c e _
Condition of system/other comments:
DEEP Rmv FO -12,071.95
r�
FORM 4 - SYSTEM PUMPING RECORD
CURRIER
SEPTIC & DRAIN SERVI
"Xi
107 FOREST STREET; MIDDLETON, MA 01949
(978) 774-2772
CCOM ONWEALTI-I OF MASSACHUSETTS
iv, (dcq"-1 MASSACHUSETTS
SYSTEM OWNER: SYSTEM LOCATION:
U vi
� � � � �� _�. �,,� � � �,�� �� a � '�" �c•�,.
DATE OF PUMPING: !lit ' QUANTITY PUMPED: )S GALLONS
CESSPOOL: NO (_' I YES F—] SEPTIC TANK.: NO F-1 YES
SYSTEM PUMPED ICY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE: l INSPECTOR:
THE PROFESSIONAL EXPERTS r
IN THE SEPTIC DRAIN INDUSTRY D �Q.1p�ta T
FORM 4 - SYSTEM PUMPING RECORD
Commonwealth of Massachusetts
Massachusetts
System Pumvitzcord r�
ystem 0 mer System Location
�r�g-1
wtr
Date of Pumping: Quantity Pumped:f .�. gallons
Cesspool: No/�] Yes ❑ Septic Tank: No ❑ Yes
System Pumped by: ........................... . .................... License.#: ......,....,,.......,..................,..........:................
Contents transferred to:
Date Inspector