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HomeMy WebLinkAboutSeptic Pumping Slip - 53 MARIAN DRIVE 3/16/2016 ^ Commonwealth rfMassachusetts City/Town of No Andover ���*��� ������.�� ������� ���~��� Pumping�� " �~° . ~~ Form 4 DEP has provided this form for use by local Boards cfHealth. Other forms may be used, but the information must be substantially the same as that provided hen*. 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 |000| Board of Health or other approving authority within 14 days from the pumping date in accordance with 31OCyNR15.3G1. A, Facility Information Important:When 0|i/.Q out forms 1, System Location: un the computer, r�ian Dr use only the tab uow key m move your *oomoa cursor do not NoAndover MA -_-�-- use the return --�----��--��---��---�-�-- ----���� �i Code City/Town State p na key, City/Town 2. System [)vvO9[: �----" MoUo|o Name Address(if different from location) Qty/Town State Zip Code Telephone Number B. Pumping Record 1. Date ofPumping oum 2. Quantity Pumped: Gallons 3. Type ofsystem: El Cesspool(s) Septic Tank R Tight Tank E7 Grease Trap R Other(describe): 4. Effluent Tee Filter present? Yes No |f yes, was itcleaned? [l Yee 0 No 5. Condition ofSystem: 6. System 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 Signature of Hauler Date Signature of Receiving Facility Date t5'orm4.doc-03/06 System Pumping Record-Page 1 of 1 � ' � Commonwealth of M S Ch(A tt x w City/Town of No Andover System i 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: Hat on the computer, 1 use only the tab 5 key to move your Address - cursor-do not No Andover Ma use the return -- key. City/Town State Zip Code 2. System Owner: Name nnan 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) kSeptic 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: Name — -- Vehicle License NumberF,,."t Steward' 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 .d City/Town of North Andover u System Pumping r � v � , Form 4 h 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 CM 15.351. A. Facility Information Important:When filling y on t only the tab 1. System Location: _ + on the computer, ` 0� key to move your Address cursor-do not North Andover Ma 01845 use the return key. City/Town State Zip Code 2. System Owner: Name remm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping ec r 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 ❑ No 5. Condition of System: I (x)d . .� ,.p y 6.,--System Pumped B Y 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 " _. .. - rgriakure of Hauler Date / Si natu ..._F �..._.. . ------- �� - -------- - g ARe ce ivrng Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts Flo?,City/Town of No.Andover y tem umpin ec r 7it"h"is"TRM,Farm 4 L DEP has provided this form for use by local Boards of Health. Ot he information must be substantially the same as that provided here. Before uck 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 1 LSE - —� 1. 1--- - ---- — — -- ------ ------—---- ---only the tab key Address to move your No.Andover Ma 01845 cursor-do not - - -- — — — use the return City/Town State Zip Code key. 2. System Owner: i rab --- -- Name e Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping I -�=1-= — 2. Quantity Pumped: p g y p 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: 6. S t Pu ped-By N Vehicle License Number tewart's _ Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill----Bradford,-Ma 01835 — _ -- — - — - Signature of H u r D to signature a iving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 look% `' Commonwealth of Massachusetts City/Town Qf NORTH ANDOVER, MASSACHUSET System Pumping Record.. Form 4 , DEP has provided this form for use by local Boards of Health. The System Pump`ng Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When tiu►r,y out 1. System Location: �� tonne on the computer,use CIIJ only the tab key Address to move your rx-4 . cursor-do not CItyfrown State Zip Code use the return key,-. 2. System Owner Name r Address(if different from location) city/Town State Zip Code Telephone Number B. Pumping Record > 2. Quantity 1. Date of Pumping ate tY canons 3. Type of system: [] Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe); 4. E=ffluent Tee Filter present? El [] No If yes,was it cleaned? ❑ Yes r-1 No 5. Condition of System: 6. System Pumped By: ��=V e Vehicle License Number a7l Company 7. Location Krhere contents were dispose , SipnAturo of Hauler Date http:/twww.mass.gov/deptwater/approvalsgSfQn-ns,htm#inspect t5form4.dw 003 System Pumping Record.Page 1 of 1 ttr' w, I, {,t , ��44q� EIVE D r 1 I c " MASS S T-7 111 NDO "pP 1,0VVIN b V (1w Po% ol 1h1J ICfln 19f 4IQ % PAMMENT 00 I,:Oj(I1111Pd11C 1111 ICC11 6CIJC 1''1 n0011n pf p{npr ,p�,p ,�'"��mm ���/ I�a.�� C {•"Inprlry A, ty In(a�rrl flan -^J CCB�On; 'mS•1 G'>� fl lJffi''•I,'�,�',''r', ,Gt��,� I / 'C �o. � t:/�,""IV�C(,!'�'r„i"" ���i,'1„I�II t', ;,�j,;..;�„.'•' 1 � SIIII ------�___... W rl`l ��I�I'S�ilr JJf r1 norf ' �r�,,,L ,i''%',I,4P�1.'�y'I'1�i'''„p„v f;'I,.,• ) fir,. f/ ' I,,.' ,, r.".�Il�i�'1�;1�' ��1' Ytl�'I'''yY' 1�''•fl: .1", d/ �„F„�� 7 '14T'14 (I 4 111n1�r 24/� �a �—� Vvn) c Pumping'RQ'go(d ' r �� t. Oelq oI Pu'mpjn9 '' Cif 'rYPI Gl iy�lomi'.; Ca>>�oal(�1 1 JVj7l�c T80A r o,pno Y to ����`,%j;.dill'Ir''�!%✓i '1i11�,1��1j l�i J��')1,/ Ij�'11i'' 'j. ye'J, n'611i CAP anPV� '” ye $ `- .. 1 f . 1 1, '','''`n.l,�.,l„`9•;�,1�1 yll�ld`I'1 ir'1 ' '11,1 ,�1' ,., . , . ,A,,{;,^�4•,'I/,;�y 1 , Il' It� ''I' ' � ���` �1+ C1� JG4nll h'IYT. . i'P'4' •'/,,(,I„ .�/,ir`�My1�14 ((�11dCyf��lll ('l'�11,�t�1i1/,l','J� 1;''I, rr :••.` ',', I.tl,;,�l' '1�,”„°,s,olonlonu yere dl,po��s�v, :r,,w.ma hJ,poYldo p�r+afoila pp/9YaJallblorm�.n:m n� DO 1✓ R:, �IASSACHUSET7S )EP.haa Q0 ;h1# (orr) ror uav �'y tQCOt Boa( n av a,.�rY Iliad lQ lhv local 8oarc C'r naalln q (, a"' �� p Sy �Qm P.! b Qr olnvr OpArQ✓Ind aulnOrlry. A, i a- IIIty Infprrrl� „.:�� tlon :.r (- 1 11 A �.., Locauon; oPQ1 I.Via nwm•y;': CItY/Tgwn , S P�1 77 --- — �;( ,l Il.,, System Owner, N 1✓n 1 'r,i, 1 nl ran bGeUon) 61 T717-11-0—(147 B,' P,umpinq Re'gord 9xy_, t �3, ,ryp�Pi eyrie m; Boa�9 ,. Cogs I ) C Sopl!C Tan/, Eh1uon! flee FIIIe(P��sanr7 Yo9 no it 4. . 1•'rr,��; j,I��'r�l �jr ra�p�t t Y89. i� Yes ,,,', ',:;• ba'Condl�lon'p(;8y�,�m;''�• ' _ It..I .... 11,! PVmped 8y:' VIII j 9j �1G9f1+4 N • '.f,w:!'�„/'” t l,'!i(�vvM1l ti', 1 Y I'I� I r�r, / it • !�r,.�',.,'�.lL, �/i:wJ�''�,!A� (Y',��dQT,;/jJ�(JI�, ����,�� �il�'?,lill� on.whera coOl�nla'yrera dlyposeo, Q1HJV4 r'y/•'jJl�,.,.,,.,.,I 9 p!wal�r/epprOYaJsJlblorm�,h mningpecl ;gyp c�;v I� ftpwlgyllprq!+, t DOVER ( r�. �• 4" OR �.' .,nC� .,�1. �' t •'i�Jaw F�y'�J1� +I�,.IM,� (/ ,lll�'. .. ,I•xl; ry+r ��°'pgge ,y�/J Jf4 t�Kll rlr�.l'r 4 t� I •''''(k�r r 4v1'{�I' t,li Vl`�+rl ylii(r 1 w I +,,,c,. 1 Ir4r� i� Y + • 14,4 U c i J• 1. i ,r•r. I r. I.,I! `JI,f,.�P•, ,' . I. I EP-,has prdvlded this form for use by IQcal Boards of Health, The System Pumping Record must ,be aubmltt®d to the,local'Eoard of Health or other approyin authority, ��A: FPPiiitylnfortMation riYv n'f�► q out ;1 System Loudon on compuw.'us"l only the tab key Add ress to move your pot%` ', Vqt I own xe r State ke a otul 7. Z1p Code j,2 r+ � System owner, ! .�T rf• �yy / `'MI Ik.r. t I,�. i�{'t 't (a" Jal .'tj1 Y °r• • ,,'�+�• , , ;;rr Nam® ''I:;-� lY4•, r — �.I:'•�!� r i •�, , 'r' ,fir ' '�' ' ';r Addrosa(It different from locadOn) ; , CWTOW11 State' p Cad Telephone Number P. �' fq 'of P umping Cu antlty Pumped; allon,.' Type pf system. s) Tank , ® Tight Tank 'Other Oescr&) t I 'J 11' 1 ,. ,+114 l"i t' .. 4r Effluent Tee Fllter'present7 ❑ Yes [I No* If yes, was It cleaned? ® Yes ❑ • t Na I�NWndl,Uon of;syst tT1r+ ,. .. . ;. t `•5 rr a" � a fr'4. �✓(� 1 t J )nl+it�I« .,� .. .. v ! r �tl Y;'4'+v,S,vey;•(',{1r;'SA'(;!;Et l.h''•'�. , Sy Q Pumped 6y:�'" C) 1, 9mo:;'1`;4�Y,' ",TI�a °'t{;j".;�w 1�� ,, ^'/� V©hlclo,Ucon/*teNumbor rr''h"'�`'r�a?}',`�l'T�'`'V,� ;:��i.r •�, �. •ti;i'�1�.�:'��;.� ,wAti� ,Qfj ,yJ,p•>Ir.f �y'+�'�,+ 7r7!4tltJr,fl� 5'�..• 4✓ / u✓{ ' ✓ � •,r l ln•'rdy,;71�}"'(,�'�r N u,�'Iy�'Ir �IZI/}�/� �+I,��a ,�l 4'trlp ti E / 1•e; v7°'IaJN•rli.YaY'�yvl •r, .t fo �', ;7r, L�ocd6n.wherg nt' yvere dipposed: �':.r. ! r `.;i ✓I t 1{I.. 'l' r I,Etv.tll, t ./ v ?I I, . '.vy. •� �l!•./ rt•ir a '�;!;a t,`{: Sl�natur®of HaUk+r:t}�`;;�>:':•a r. •!'.. Date httpJAwAV mass goWdep/,wafer"/approvals/t5formsrhtm#Inspact • t5f .doe 0 /03 ,� System Pumping Record Page i of i ✓ }Y iJ4� A�1 ,�6 4 1 .I. i � %�. ,mow hutt5 t MASSAC • ld�v,p .x. 1tAR�iW ! 9 I �Vl1 . k.f,,.. ® 6 ktH ,, LIr� ded ���W 4(aC-r°�G�`�RIHA��:.�� ���wr v a, R : r P t���' ��:�1"d �.N Fa�rrrn 4, ��. . DER 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 infcrrnaticn .Important: When Y r filling out 1 S• stem Location: 4 forms on the a , only the v ,, computer,ws® f _ � � to move not Address .�, (, t � � d Use the return Cityfrown State Zip Code key,, 2. System Owner: m � Name Address(if different from location) Clty/Town State Zip Code Telephone Number B. PUM"ping Record 1. Date of Pumping Date 2• (quantity Pumped: Gallons 3• hype of system: ❑ Cesspool(s) A S'eptic Tank ❑ Tight Tank ❑' Other(describe): 4. Effluent Tee Filter present? ® Yes No If yes, was it cleaned? ❑ Yes ❑ No 5, Condition of System: 6. Sy em Pumped By: hc' Name Vehicle License Number Company 7. . Location where contants,were disposed: Signatur of He ier Date http://www.mass.gov/dep! ater/approvals/t5forms•htm#inspect t5fomm4.doc•06103 System Pumping Record-Page 1 of 1 5 11 Y5l/F I+il.t,h 5; ' 4r5ty1�II`��Y ltlli' � tf '✓`.f s , ,,f llnavr�livr 5`,t,. ,"� y TOWN Ur Y878h'1 PlJMPINU R-P-00kt.. eeV � .� e w v.rrrro �I✓Vri .,. �Vouc �� rvKb car 0,00"OHOITIUN ,�NVl.11 ( F t'i7�rx R4AYY QUA38 B�YYI 85 IN KOM.: �rXC�9�rY� °�l�lD� �a p a Rvivbn��r, $OLrVOA KA Yq"A . ,..0�(�R �XPIIaIN l'vMM�hlr�. 4 uN ►'�N I'y rll�hryY��GKbU �'� r TOWN OF NQkTH ANDOVE? , uA t'L SYSTEM P LUMPTN Q RAC:"OR1t ) SYSTEM NER ADDRESS SYSTEM LOCATION DATE OF PUMPING; �. .., r.... _ __. ._QUANTITY PUMPED::.� .._.. k-*0SPOOL: NO— YES'.,. _... .. Sbptic 1'n.rlk: NO YES NA rUkl; OF SERVICE: ROU'rlNE,.. E►�1k:'RUENC'1' 08SERVATIONS: f 1l::,,,., (�0/. QOOD CONDITION , '-FUL..L. 'i'U COVER HEAVY OR EASE BAFFLES IN PLACL,R7CT9 , 13XCUSIVE SlJI LDS FLOODED RU1V13AC K SOLID CAft RYpVEI ...n OTHER EXPLAIN �yrtrorn ('tamped by .... �o. �,'UMMrNTS. CUN rEN I'S r'KANSL°'hRRED r() 6 r �tl ti1 i se,^y , RQUTIr C T ElnERCc:°,; I � FA OCve' sS� lUy C� R�}YOY'PR �� 1 1 11� PUm ('CO''0 r TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: b: SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) °3 MO-/?A" �I Oindom-, DATE OF PUMPING: �Q' ° - QUANTITY PUMPED GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES _ NATURE OF SERVICE: ROUTINE ✓ `, EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: S s rh, I 11p� /,d( vet- �}� T'S SEPTIC TANK S JV,d f1 h A BRADF®RD® to 01535 del u l L j e- 1 C'/ co 14 975-372-7471 PmTm OF � YCWMY REPORT FM TCWN OF fU� h rxa ✓ � DATE S GALWNS e-13 � 0 "7 M tVm •fir SJ—. /hZ,0MeQd6c0 lid o 33 2 f