HomeMy WebLinkAboutSeptic Pumping Slip - 60 PATTON LANE 3/21/2016 RECEIVED.—"'
Commonwealth of Massachusetts 0(1:�
u"�
�, Herr
System Pumping Record °
Facility Information:
System Location:
U (I .
Address
o�-46 C C 1 11Y1
City/Town State Zip Code
System Owner:
Name:
Adress (if different from location of pump)
City/Town State Zip Code
Telephone Number
Pumping Record
Date of Pumping Quantity Pumped ` > gallons
Type of System Septic Tank Grease Trap Other (what)
System Pumped by: & /
Company: ROOTER-MAN 46 Portland Street Lawrence, MA 01843
Location where contents were disposed . '
L`�
Signature of Hauler. _ Date
41 P,
Commonwealth of Massachusetts
City/Town of
System to in ReGord NORTH ANDOVER
Form 4
M-y
l 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 frorri fherrpin date in
accordance with 310 CMR 15.351.
D
A. Facility information
Important:
�d�rtrl �r ii i, r i
When filling out 1. System Location:
forms on the
computer,use ---
only the tab key Address 1 ���.. �� /,
to move your . _.
cursor-do not Ci y/Tawn fate Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location}
--- State Zip Code
Cityf own
Telephone Number
B. pumping Record
1. Date of Pumping f-- .._.__-- 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 Stem
6. System Pumped By:
---
Name , Vehicle License Number
Company
7. Location where contents were disposed:
----- - -- - _ - __
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record-Page i of 1
f
Commonwealth of Massachusetts
City/Town of
-- j
System 'n Record TN or�NORTH e�
Et
ALForm 4 TOWN
DEPARTMENT'
TMENT
w h nw auquwwwwwre
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 tilling out 1 System Location:
forms on the
computer,use - X-- el only the tab key Address
to move your ------------ Zi cursor-do not - State P Code
use the return
City/Town
key. 2. System Owner:
VG J-
_ r - r ►_
- -- -
Name ---
� Address(if different from location)
_
Cityfrown
State Zip Code
Telephone Number
B. Pumping Record
:.
1. Date of Pumping - J j — 2. Quantity Pumped: Gallons__.
Date
3. Type of system: ❑ Cesspool(s) ®' eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste '
6. System Pumped By:
w
— ---
Name Vehicle License Number
_ IV ----
Company
7. Location where contents were disposed °
sign—awe of Haul----er ---.----- ---_..—. ------- Date
Signature of Receiving Facility
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MA SA U
System Pumping Record F UT Eta
Form 4 `
,JUL 0 8 2009
DEP has provided this form for use by local Boards of Health. T e stern pwumpin Recor must
be submitted to the local Board of Health or other approving aut or L tit t i u�aTt�°' r�vf..R
pp g ��a�o-t r.�t:�u ��vtm~u�a
A. Facility Information
Important.
When filling out 1. System Location:
forms on the j �, A\- Y)computer,use l
only the tab key Addr ss
to move your
cursor- nat
use the return Cityr ow State Zip Code
key. °
2. System Owner:
Name
F`� r Address(if different from location)
City/Town State Zip Code
9- —
Telephone Number I
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: Gallons
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 E�/tvo
5. Condition of System:
a0(„)
G, System Pumped By:
Na e — Vehicle License Number
Company
7. Location where contents were disposed:
Lawr&nCev MA.
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
_ orrlr-lonwealth of Massachusetts
�w
City/Town of NORTH ANDOVER 9 MASSACHUSETT
-
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pump"No, Record must
be submitted to the local Board of Health or other approv ng a 4.1,7 ,y
A. Facility Information
Important: �..
When filling out 1. System Location:
forms an the
` � i� r�
J'�
. l computer, use ..
only the tab key Address
to move your t
cursor-do not � `b� `� ..
use the return City/Town State Zip Code
key.
2. System Owner;
Name - — —
Address(if different from location)
City/Town State Zip Code
n-
_ ..w 14
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
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, System Pumped By:
W
met m Vehicle Licensee
_.
Na Number
Company
7, Location where contents were disposed;
Signature of Hauler Date
http://www.mass,gov/dep/water/approvals/t5fDrms.htm#inspect
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
Commonwealth,1l°th cad, Massachusetts Fo Sys rena Purnlarng,RMrd,..
a scaChr.i, e'tts R E „,.,,<%
stem I unipi ac o Record
System Location
. ...... ........._. .-._._,io_u_l rn_
. ,...-.m. -......___.....__._
w.r.
Type: me gerc ��T--
_
Cesspool: No Yes Septic Tank: No 1 Yes
bate of Pumping f Quantity Pumped: / Gallons
System Pumped By: Wind Dive Environmental,LL C Per mit,
Contents Transferred to:
Contents l ispaosed af:
..... .--_------_______ _ :__._....._._.w.____.
bate: Pumper Signature: _ W . :_. ._ � ..,_.� ._._..__.�........
Conditionof System/Other Comments _-_ ........_-.................._._....__...___._. ........ ....................................._................................--------
m„_,.,,..,_.___._.. _..._...._............_._ _......_._
bep:a Approved Form- 12/07/95
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSAGHUSETTS
( = Ia
System Pumping Record
_ Form 4
DEP has provided this form for use by local Boards of Health The System Pumping Record must I'll be submitted to the local Board of Health or other approv Ong a4149 ( F. WED
A. Facility Information ��U - 8 2��0(6
Important;
When filling out 1. System)canon: c L TUA/N CH. 1,
forms on the
computer, use
only the tab key Address
to move your &-cw �, Rio ele)tle e-
cursor-do not —
use the return City/Town State Zip Code
key' 2. System Owner:
r
Name -- —-------_ __ _
learn i — --
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping babe �' 2. Quantity Pumped:
e Gallons
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. System Pumped By:
e
Name / rr_ Vehicle License Number
G� I�
Company -- — - ----
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/waterlapprovaIs/t5forms.htm#inspect
t5form4.doc 06/03 System Pumping Record •Page 1 of 1
Fom 4 .._ System I find""pt o'—rd .
Massachusetts
nh Pra firk R1
System Owner System Location
3;;;7 rioutinc
Cesspool I"+irs 1',1"" yep "
Septic tank; her Ows
bate Of anrpdr ; �C Quantity Pumped: Gallons
Sysftm Pumped y; Wild Rivera Chviroftiviental, L. C Permit :
Conterdsftwwferred to:
V fl,,,u D
1,l 777-71-f
1
Contents Disposed at: East Fitchhurt
Wan Ste Water
I?ate: Pumper Signature: ul
Condition of Systecyw/Othw Comnvents
bep Approved Form - 12/07/95
r(w,M At System Pumping Record
Camay mvealfh of Mossachusetss
Massachusetts
I RECEIVED
J/ -A J
Jul. - 9 200.
-rOWN OF NORTH ANDOV
System COMMI, System ...... ......
R'
0"
C
D
rc)w JUl"
N OF NORTH ANDOVL
syst,
Ty":'
Cll. k N. Sep -
tic tack No 0 - ED""
O,t..f PMpl,,g,
Quantity Pumped: Gallons
.System Pumped By: WW Rla r Envitwatental, LW pelvalt
Contents transferred to:
Contents Disposed at:
bate: Pumper Sig"WIV:
Condition of System/Otlwr Ca ants
Dep Approved Form - 12/07/95
F .._ System M#mpinq pccaaa'°.1
Cowmnwmealth of AassnOwsetss
Aassaachusol°tic
wy�s agmaa w� ������.N� y t s� tiara ..��� .. ��m� .........
,r
paaaztir
swpaarA: "P Yes uptick MW w Ely-
ate.of uu"On ! —6.3 Quantity Paumpe& Gal' rrs
m"uysbun t uwa almad r"tya w1aa,rl Nw are uaV#w'avar ental Ile Permit M
Cwftnts fransfraw° to:
aarrtcartw Disrx0 e'd at.
bat PUM;MW siatuaaataar
it°m wua a�' y t au°wr t a�a ar raau^maaaat r ..w.w ..w w w...v.....
beta pc°ove Form 12/07/95
Frans 4 .._ Systmn Pumpfrq�itacar
Co a wn eaith of Massachusetss
Massachusetts
System Owrwr System Location
Tyfwe, Enwwsrgerory Routine
asspook i s rs Septic tank: yes
Date of paaurrpir : 4 araratity Pumped: ( l aligns
afftents twVns'paa i tra:
Carrtents Nsposed at:
iw'arate. Pumper Signature:
COMIffion of SYSIOW00wr Comments
I
Deer Approved"`r om - 12107195
r
'i,, ' .Ott ?4.SAS,�L1 PJ�,PC?�, iECORD
0449
(9 is 174s�'?72
STsi�t aWNc12
II �XSTIc.M L�JC,S�'7�N;
DATE OF FL'rfp1:1�;
CESc'PQGL: NIO
S8'� C T�-N A_: G LD YES ?
SYsrp.M pn B gCt� UR Spa°re & Sk
Co MINTS°l lANSFE D TG:—M.. J
23 001
Ri
07 Forest S d, ��h FORM 4 ° SYSTE M Pn'PLNTG RECQIW
�'78(o 7,1-27i2J
Cog , a
r n
COMnxonwealth
of TViassachusetts
roc , Massachusetts
_,
� �`slei�I (5���nc:r
f
��/�fT/''�"�� ystern acatlon
� rr JJ
� ✓ �' f It /l''r�r (7�) ���7` C �., �/aA�T-� O�
'r-ce C,(
/ A-/
I ;le of Pulliping: rF S= �� ✓
Quantity Pumped: � allons
C spool: No ❑ Yes ❑ Septic Tank: No ❑ Yes
Svstem Pumped bv:
- License 4: .:
C:J"teats transferred to:
----- -- _: C Inspector °CIV� �'
0 THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0 '......