HomeMy WebLinkAboutSeptic Pumping Slip - 17 LACY STREET 3/15/2016 . '
�
Commonwealth of Massachusetts |
/City/Town of North Andover
System, Pumping Record
Forai 4
DEP has provided this form for use by local Boards of Health. Other forms may be _used,-Vd. 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 tu
within 14 days from the pumPinQ data i»
the |oca\ BoardufHea|thorotherapprov\nQau th ority
accordance |!
with 310 CK8R 15.351. - \
A. Facility information important:When
filling out� /nns System Location:— '
on�mcumpmn,.
use only the tab
key tn move your Address Ma 01886
cursor do not North Andover State Zip Code
use the return /Town �
key.
2 System Owner:
Name
Address(if different from location)
State zip Code
cityfTown
' Telephone Num er
pumping R ecord /5W
I. Date of Pumping Date 2. Quantity Pumped: Gallons
I Type
F] Other(describe):
�� Yes Fl No
4. Effluent Tee FiMerpresent? El Yes E] No 1f yes, was Kcleaned? �� �~
�
5. Condition cx System:
�
S, st
e icle License Number
Nam
Stewart's Septic Service
company .
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Date
Sign re of Hauler
Date
Raovm Page
3ys�mPvm�nO '
��n����oome �
`
Commonwealth 11'Massachusetts
Noah Andover, Massachusetts
System Pumping Record
�t
WED
System Owner cot Address:
Scott Rundle M.; `k �� "
17 Lacy Street �ti���H i pd" )OV R
North Andover, MA 01845 —2'rU
Location of system: Left side yard
Date of Pumping: October 30.2012
Type of system: Septic Tank
Gallons Pumped: 1500 gallons
System pumped by:
Service Pumping& Drain Co., Inc.
S Hallberg Park
North Reading, Ma
License#: BHP-2011-0413,0412,0411,0410,0409,0408
Contents transferred to: Greater Lawrence Sanitary District
Date: Oc her 3Q, 2012 P'urnpifig Te%hidah as
This is PROPRIETARY and CONFIDENTIAL information that may
be used only by the Board of Health for regulatory purposes
(f b � Y (Y
/.�I(v..,o Y �
Commonwealth of Massachusetts
- W City/Town of Flo. Andover "
1
System Pumping Cord ��"�rv�'�ur,��`i�1r�,� ille�i<<i�(°�°� et�
Farm 4 �i �
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 on the
computer, use 17 Lacy—St — — —
only the tab key Address
to move your No. Andover _ Ma _ 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
r'"'
ae Rundle
— - - --
Name
— -- ------- —
emm Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 4/12/11 - 2. Quantity Pumped: 1500
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
5. Condition of System:
xsolids
6. System, Pumped
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 Da
Si nature of Receivin ag Dt
t5form4.doc•03/06 System Pumping Record •Page 1 of 1
t,,'I�Jrar s ��` 4illtlli,�'f�f(�l�i•'"+' `�
ri I
1 AC E r
II
�l�'lli'�v� (,
NOV 1 0 A��� ��')
oep,hdr P19Yl0fd
!hl/ lalrn I r
or Ivbnv pro
Cl to rh1 Iocrl 8crrcr c'r np�
A,
ry Inlarm�llon
.rt r.l
I
r ,r
,r
r ,r
rr, ,
rl
r r .
"1 Y4 � ri•,�I I�ril(Ir')Mlrl ,'rl rl'r/Y�'�Y,
, r ,
r ,
_
777 u
'�'IY'IlI , I 1r 11x111/ '
2 —9,2,��T( ' 4�i5 --------
r
I'
r
r
I 'dC� hwu Ilv/��ntir �'
r
i
' I ' Oa44 al Pam'
plop';,
q .,
-ITS r. �r �1'yp� p� 'r�lomi,r� '�
�I�'rr r) Y'I'i Ire ,.�9D1•C Ten, � r
r (dosc,ribo1;
, r
4r; MUo� �1/4�1y11o(A�(rRraanr? r' Yoe m a _
•";^f:, `,J I��w,`f�ll'1/r�,' 'I"�/rYll f,t�,!���ii/�i111'i�'�'";'/ II y9) n'9 ) II C'tl dn00� !`1 t( S „ ,�.�'°�.
• � , ; it ,CQ�dyon P�,,Sr, �ryy� ,� , . � -
/;, r,l•I�,'.y/� ,r l i , I % ..2�>
Poo,6r;' r
•;'�';Y I,�''�'•' I�� '�j(J(r �,, `�1' r'r 171 Y' 1I/�J!,� ,44'� i' '�� �� '/
'^' •'Ih 'r�<^v'�pl/�1' , ' II,' 1 II ,II'' ' ` ' I� I iI�I�I IJ�nII /"t'r""'v l/ --...
1�•,aryl,/�,r." , y .�• �� a �� �.,,.
' .I I,; III dl�posoo;
' ;Y' I J,1 �' •' 'ISl3 I/r)�,�'''l/l'i,'�'�I•�i / / I�
may,q .
orl Ooproloi lipp�ora�s/141orma,rrrmain �nl