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HomeMy WebLinkAboutSeptic Pumping Slip - 66 MARIAN DRIVE 3/16/2016 Commonwealth of Massachusetts ❑_� City/Town of North Andover ^( r System u in Record 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 , ate, ...... Important:When .1 lA'1 �.,R„� ❑,. �, filling out forms 1. System Location: on the computer, y use only the tab key to move your Address cursor-do not North Andover Ma 01845 use the return — --- key. City/Town State Zip Code 2. System Owner: rob Name e1um Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record /U 43 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 5. Condition of System: vl � �. ( J l 6. System Pumped By: ❑ = Z� ❑/ Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: tewart s_Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 �.._..___.._ . ....... Signature of H uler Date Signature,6 eceiviugciTtC '=— - Date t5form4.doc^03/06 System Pumping Record^Page 1 of 1 Commonwealth of Massachusetts CityrTown of r °t Pumping System gnu p d ju N i Form 4 � .. information must be substantial) the same as that provided hire. a orb iasi� fhls fiorm I�EP has provided this form for use b loom Boards of Health. Oth r fc� ., y p ng , 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 CMP 15.351, A. Facility Information )oftant en riling out 1. System Location; ns on the .,y ... ��r,use L.�.�. ) ✓the tab key Address nova your North Andover ma 01886 sor-do not Cityrrown State Zip Code the return 2. System Owner: 4• m _ Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record Date Ga 1. Cate of Pumping 2. Quantity Pumped; Mons . ....,�. 3. Type of system: ❑ Cesspooi(s) - 'eptic lank ❑ fight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ® Yes ❑ No if yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Sm stem Pumped y: Name Vehicle License Number Stewart Septic Service Company 7. Location where° ntents were disposed: Stewarts Pre tre en Plant 20 So. ll t Bradford Ma 01835 u nQ'�tureof tr er �..... Date Signature of Receiving Facility Date =M.doc-03/06 System Pumping Record•Page 1 of 1 DOVE R: ,SAS Il if�7�„r ,LIt YI,�y' ,r'•,',�1';",yl.i j �.1 EC ,„.;„,,,,, „ SOP hey p 100 fhli loam I r eo `,' la;ai E3aalcr or ,�y ., Da �'„oml(IOd Ia Utv Ioc�1 BCaI�: � i „ao,i a� Cl � p „ .y. I �• Ifr���"pp G,� .l "lnprlr A• Faculty in(orma clon OF NORTH AIqD0VEFR h HEA C DEP V14 n'I m -- .;� Sya�sm OwnQr 1 Z-5/,� , /ddrH� (I 00111nl Npm "Ocn) — - Cq�o n -- ,, - i P�m'pIng. 3, rYpo vl ey�l�m, Co9s�ooi(s) O Saol!c r©nA (� J;hor (doacribe�: q,, `f o FI8o( enr? Yoq �] n ' �� i�J•�i,1rr� l,��j1 ���'r�� a y69 n6) it c'98ngg7 '� Y?5 _ Co�dl�lon'p(9 - � r � I SY P4lmped 8y �.1.�,'''l,!�,����•� -Pv'I%�'"'i��'�;"; `����>�'•iYi''d��;, � VIhIG14 'JG9n�1 h'..�^„ __ '1J, . loci 0 n' '' r �1;•I:\,. I ,;l �rh�r� corilenla•war� d�sp\orsleo. 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' ,' "1/I VIr1/ '�3•;.I,,1 i1\1' r , VLale yI (',^� T®Iophono Number 5 ''I sir rrl UrRPIn�'�0 ViNr l�l��'frr l5,li:J''. �yN�Il9,lrf`"I(., r • ''1 Date o(pumpinq`�' oa o 2, 'QuanUl Pumped; � - r, 1. C ,I '•I� � � GdIlOnO "TYP,® 4f,sysl�m '; ' °' ] Cesspool($) epUc Tank Tlghf Tank ,t;' b,{,i 11,,,t.,)�lti.1.,'16'�,'�'Ifh,t.'•)t!�,,V'� �, r an,t�'.,� o' es was I If Yes, CIeaned?f Yes � N ... ;rr,. ', , /y."`' 7''Ay.'Yra!ti✓•,lY�'•u,�/,�,,.+GfU Illr'rritl'1' '/ a ,�,�aContliJonorsy; '41y1 . h, Y+ 1 )1'VIY r/rl �1'I,I,✓ i y .L.'.,,1 ,Iq I{11,11,1.'r, ,r� .' � ..n.,! 1,j,,1',1'1�'Irl'4II G"v... ��l✓r,�i�l�'1 v!�{r't�3��'�t'�q' ,'� iii%i'r( 51 :1.• ;`'t".',�',! 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YES SOPtic Tank: NU YHS NA rURE OF SBR I ^s�UU rt,r� '.,.�w,..F;MERcaENG"y ............. UbSURVATIONS; cowrrioN ` ULL 'M COVER REAVY O E BAFFLES IN PLAU, R LHACKFIELD RUNBACK BXCUSSIVE SOLIDS A.Rm. FLOODED SOLID Cr4 YOVER. ..,.. .OrgER EXPLAIN SYstam Pumpcd by .... .. VUMMENTS, L-UN mm's rKANbr,t:xKED rc, TOWN 01" NORTI-1 ANDOVER SYSTEM PUMPING RECOR-D A I I. S !'LM OWNER & ADDRESS SYSTEM LOCA'T'ION � (ezamPle, Icfc (rc,nc �f I�au�e) r lP P r1l /fA 1 L OF' pUMI'INC; '" -'� '1 QUANTITY f'a���1I'[�:D/� � C,vLL(�,��; 1 OUL; NO YES SEPTIC' TANK; NO YLS MATURE OF SERVICE: ROUTINE EMERChNCY t l)>f'R V.:\T I 0 N S: COOD CONDITION- FULL TO COYEN _ HEAVY CREASC BAFFLES IN 1'L,AC,' _ ROOTS LEACHFIELD RUNBACK _ EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER � O�HRR (E:XP A !N) >1 5'1 Lm PUMPED LAY; �. U 1I ^rl FLATS; I.'N' ,5 '-Y ANSFCIZIZLD TO: 04/06/1997 15:02 50837; 6611 STEWART/INDOV R PAGE 02 A1,64i A1VL6vr-r 12,n. 4. )Z6 �1��n �� �P$ A/4 e4i 47 � � v MA 01035 L' 978-372-7471 MONM op r 0c)U R mm OF DATE J m 5'I c.3 4 . 1