HomeMy WebLinkAboutSeptic Pumping Slip - 15 LONG PASTURE ROAD 3/14/2016 Commonwealth Of Mass Chu ett
=xa City/Town ®f /Vo
System Pumping 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
filling out forms 1. System Location:
on the computer,
use only the tab ---
key to move your Add
cursor-do not
use the return --
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ecr
1. Date of Pumping — 2. Quantity Pumped:
SAOL 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. S stem 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
Oa auler Date
eceivi acility Date
t5form4.doc•03/06 / System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts .w -'
City/Town Of NORTH ANDOVER
u%:< 1, Hew
System Pumping Record t
Form 4
111 4Ot' VFL,
DEP has provided this form for use by local Boards of Health. Other fa „rinay be used,, ti e
information must be substantially the same as that provided here. Before using this form, chreck 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 _- II , °✓ --t
key to move your Address
cursor-do not NORTH ANDOVER _ Ma _----
use the return City/Town State Zip Code
key.
2. System Owner:
Name
/BIWR _
Address(if different from location)
City/Town - — State Zip Code —
Telephone Number
B. Pumping Record
,._ C.. 2. Quantity Pumped:
1. Date of Pumping Date p 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:
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 RReceiving°.FadUty - Date - - -
i5form4.doc-03/06 System Pumping Record>Page 1 of 1
Commonwealth of MassachUsetts
-- City/Town of N® Andover
System Pumping r
Farm 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 r
Important:When P y
filling out farms 1. System'Location: t,i,r�i I 'v
CILon the computer,
use only the tab
key to move your Address
cursor-do not No Andover Ma -Tip the return City/Town State Zip Code
key.
2. System Owner:
Name
teuan --
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ec®r
1. Date of Pumping gate t 2. Quantity Pumped: Gallons .
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ——
4. Effluent Tee Filter present? ❑ Yes 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:
Ste rfi's re-treatment Plant, 20 So. Mill Bradford, Ma 01835
Sig at r, f, ule Date
Sig n ture of Receiving Facility w date
t5form4.doc•03/08
System Pumping Record -Page 1 of 1
aw
Commonwealth of Massachusetts City/Town of NORTH ANDQV�ER�MASSACH SETTS
System umpin Record W... ) A
�
Form 4
[ABP 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.
i
A. Facility information
Important:
Men fining out 1. System Location:
forms on the
computer,use only the tab key Address p� /'°'�
to move your 4a
cursor-do not City/Town State Zip Code
use the return
key. 2, System Owner:
VQ Name
ream Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
—916k- 2. Quantity Pumped: Gallons
ons 1. Date of Pumping date
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. S stem Pumped By:
e Vehicle License Number
pp
Company
7. L cation ere
contents were disposed;
Si re of Hauler oDae
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
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DER has provided this form for use by local Boards of Health, The System Pumping Record must
be submitted to tha.loeal'Board of Health or other approving authority,
Aa Facility Information
tmgoortant;•
When MUng out 1 System Locatlon
> fond on the .
:computer,use
only the tab key Address
to move your
( �tumt City/Town State ZIP Code
48 a 4
System 0 wnat;
. I .r � ri vl � et t r. !r2 r (.,. 1 I •'i"4 /`�" �1 .
Address(If different from location)
. CltylTown . State - --_ �
Telephone Number
•�.1 I t`' iraz, Itl/ti
LAIN-
Dat 'of Pumping ' r aal 2. Quantity Pumped: Gallons
' TyPe Pf system: Ej Cesspools) Er Septic Tank ® Tight Tank
i] Qther(describe),;
,r.
4 � Effluent Ted Fllter present? Yes El No' If yes, was It cleaned? ® Yes (l No
Qonditlon of Systh :` r
.... � C.i•' 1 r,' 'yql P �Yt:S" r'1 i .T�.' e (,��t„r� I - '
Pumped py `
a 1 C, )
I
�Vehicle Ucen$a Number
ti , � r r ame:,'1 r, l' ��, y�• t�Y�'�y ;t,� �fll..�(
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v.
Locafdon.Where oontents,.Wsrq dIpposed:
r C.tC..r
Date
6101/wwav,Mas`s.gov/dep/wetdr/eppr'ova,Is/t5forms,htm#Inspect
t5fomy4rdoo+'06/03 System Pumping Record -Page 1 of t
I,
Commonwealth of Massachusetts
g1C
City/Town of,NORTH ANDOVER
FLUSETTS MASSA .�� [ ,
r
mng Recod
System Pu ' li
'P
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 Address
to move your
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Name 14�
G,
ehrn -Ad-dress(if different fro location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: F-1 Cesspool(s) tpgp't'ic' Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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TOWN O�' NORTH ANDOVE-,?
" SYSTEh PUIVIPINQ RECORD J
~M OWNER & ADDRESS
SYSTEM Loc ATTCN
DATE OF PUMPINO;
. ..__.._OI,IANTITY PUMPED:
t 'SSPOOL: NO YES
.
SOPUC "lank: NO YEs ,
NA WKE OF SERVICE: ROUTINE4f` _ EMERGENCY 1
l
013SERVATIONS: ,
GOOD CONDI'TIONt--'°' PUU 'T'O COVER �
HEAVY OREASE _ _ BAFFLES IN PLACE
ROOTS
...._. L,E.ACHFIEL.D RUN BAC'K
EXCESSIVE SOLIDS __ FLOODED _.
SOLID CARRYOVER OTHER EXPLAIN
Syetmm Pumped by
�_'UMMItN1
L:UN 1 EN 1'S 1'KANSFhRRED I'U
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
STEM OWNER & ADDRESS SYSTEM LOCATION
(ex2rnple: left front of house)
1,E OF P U M P I N G:
QUANTITY P U M 1)CD G A L L 0,',,
(, L'5.S11OOL: NO YES SEPTIC TANK; NO YES
",,ATU RE OF SERVICE: ROUTINE EMERGENCY
i .S FR VA T 10 N S:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O, JFIFR (EXPLAIN)
,)v�TLM PUMPED BY:
CU' I M ENTS:
U.N'I'ENT' T]Z A N S F E I Z I ED TO:
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