HomeMy WebLinkAboutSeptic Pumping Slip - 26 LONG PASTURE ROAD 3/14/2016 Commonwealth ®f Mass chin tts
City/Town ®f
A 1A 4 e W� el I
- System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forrns 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. Sys em Location:
on the computer,
use only the tab
key to move your Address S
cursor-do not �!°/
use the return ° _ -._---
key. City/T0 n State Zip Code
2, System Owner:
Name _
rwwn
Address(if different from location)
..
City/Town State Zip Code
Telephone Number
B. -
Pumping Record
1. Date of Pumping Date --- 2. Quantity Pumped: a
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. Syste Pumped By:
N e "" Vehicle License Number
Ste pic Service
M _
ny
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
4
Commonwealth of MassaChUsefts
Cif /Town of No ndov r-
-_
J
S System Pumpirig Record
fr li�tltF' 4
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
filling out forms 1. System Location:
on the computer,
use only the tab 26_Loing_pasture Rd
key to move your Address
cursor-do not
use the return No Andover MA /
key. City/Town State Zip Code
2. System Owner:
rah
Devito
(� Name
/arwn
Address(if different from location)
------ -------– — 4- ----
City/Town State Zip Code
Telephone Number
B. Pumping Record
_ �?
1. fate of Pumping rya _-_- 2. Quantity Pumped: gallons
3. Type of system: ❑ Cesspool(s) 914Ptic Tank ❑ Tight'l-ank ❑ Grease Trap
❑ Other(describe): - ---- --------------
4. Effluent Tee Filter present? ❑ Y o If yes, was it cleaned"? ❑ Yes o
5. Condition of System: L
6. Systn Pumped By: _
N47r M
an Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
ill Bradford, Ma 01835 _.._
Stewar's Pre-treatment r ... �.°"�. 2Q __ ------ _ —
_— Plant, -- -�o -
M
Sigi tG' 11-1 ler ['late
i atureof c i Fa,atiR – °"` (late
t5form4.doc<03/06 System Pumping Record^Page 1 of 1
Commonwealth of Massachusetts
w
iyl.TOwn Of No Andover
a
4 System in r
M
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 l
filling out forms 1. System Location:
on the computer, !/
use only the tab C/1 Gl� rl �
key to move your Address
cursor-do not No Andover Ma
use the return CityfTown State Zip Code
key.
2. System Owner:
{� 1 V,
I
Name
ratan --
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
2. Quantity Pumped:1. Date of Pumping Y at p Ions
ate
3, Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes KNo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Zt
d
y f �A .
6. S ste um ed 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
t5form4.doc•03/06 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
City/Town of NO.Andover
System uuwwwuuuuuu�au.�.w,w, ,.pYk'? ;MN"rv^.Wfk;2,u
Pumping c r 1RECEIVED
Form 4
DEP has provided this form for use by local Boards of Health. Other forms ay be used, but the
information must be substantially the same as that provided here. Befo ur
local Board of Health to determine the form they use. The System Pumping 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 on the BMW"'
computer, use 2--,( (2
only the tab key Address
to move your No.Andover Ma 01886
cursor-do riot - - - ------ --------- ------ -
---------- -------------
use the return City/1 own State Zip Code
key. 2. System Owner:
Name
emm Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - 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 ❑ Na
5. Condition of System:
6. stem Pumped By:
ame Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
. . , t wart's Pre-tre t ent Plant, 20 So. Mill Bradford, Ma 01835
S -
,. --
Signature of Haullr Yy,„w, ��wµ Date 6 r° 17
)c
--- ---
Signature of Receiv V Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts �
City/Town of NORTH ANDOVER, MASSACHUSETTS
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 } Pa,��uf
computer,use
only the tab key Address �t
to move your I�°1�(�'i�(` V(�t M- o.-
cursor-do not Cityfrown State Zip Code
use the return
key._ 2. System Owner:
Name
Address(If different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping CrJ f� }�� 2, Quantity Pumped: 6
Gallons 0
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. T)otem Pumped By:
M�CVehicle License Number
KfA�-1� � PA tC'
Company
7. Locatl0 +here contents were disposed,
C—) 01YA lit (�-I, hnct-rorcj Ar11—
l nature of Hauler Date
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t5fonn4.doc•06/03
System Pumping Record•Page 1 of 1
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P I �li torm,for use by local Boards of Health, The System Pumping Record m.,s'
be submitted to tho local'Soard of Health or other approving authority,
A;, Facility informpti®n
� r;tm,Rortant
r,r Wheyun�out 1 System Location; � )
and the tab key Address
to move your.
.;.cx►ratx•do not
tho rotum %` Clty/Iown Slala
't-„•1�J t ,y�y�t`�,,1+ , ,;,.�;i ,,, .• �P Coda
System Owner "/
r
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1 pate�of Pumping Dot® 2, Quantity Pumped:
Gallon,
3, Typo pf system,
Cesspools) eptic Tank ❑ Tight Tank
'IQther(describe),
4r' Effluent Tse Pllte 1 ;
(p Qs®nt7 ❑ Yes a If yes, was It cleaned? ❑
Yes No
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