HomeMy WebLinkAboutSeptic Pumping Slip - 315 SOUTH BRADFORD STREET 1/1/2013 Commonwealth of Massachusetts r
City/Town of �j
System Pumping Record NORTH ANDOVER
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 Mere. 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
form onlithe B y out 1. System Location: y
eom es uter,use . - , �'" _. ( ✓ ( —._—...—---- .._......_
only the
,z /' / ( /44
to moved b bey Address
use the return City/Town / — State- - - -- Zip Code
key. 2 System Owner:
Name
Address(if different from location)
Zip Code
-�
City/Town State / ZiC.�
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: /ns
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑ peptic 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:
Z 1�G� Z.
Name r Vehicle License Number
Company
7. Location where contents were disposed: . a ,` . m
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
System in g Recor
-- Forrn 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 lnformati®n
Important;
When filling out 1. System Location: 6
forms on the ,.- �,�- �",... �.j l 7�l;+G,. .� �r � a.J
computer,use 1 7t yG�.. -
only the tab key Address
to move your /rGIJs!1 � o-Ad"w'lee"'r—
cursor-do not — Stale Zip Code
use the return CityrTown
key. 2. System Owner:
4)1'J
Name
r;e r '�
Address(if different from location)
State _ Zip Gode ,.
City/Town y
!_ - _
Telephone Number
B. Pumping Record ___—/------
1. Date of Pumping Date -- -- 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank El Grease T
Other(descri e
4. Effluent Tee Filter present? [] Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
00 ago -
6. System Pumped By. °
X66
ame Vehicle License Number
� G t ✓ --�'� u °P..l � f',l o
Company
7. Location where contents were disposed:
�r �
Hauler r
$igna ur,eI Date
Signature of Receiving Facility Date
15form4.doc-03/06 System Pumping Record-Page t of t
Commonwealth of Massachusetts
r
City/Town cif
_ - System Pumping Record NORTH ANDOVER
Form 4
OEP 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:
com uter,use a Location:
forms th
/ �° w
When filling out Y
on e �' � J .. .�
1. �em� �4N�cx�Z"�� �" � ,� �'r �„
p
only the tab key Address /Q
to move your /'�%.��',.-�r'2 ✓:.,r��' w>�/�✓"" �f.. C-- �." tip Code
cursor-do not City/Town Slate
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
2. Quantity umped: da lons
1. Date of Pumping Date Y
3. Type of system: ❑ Cesspool(s) ['Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
u p r;� r
4. Effluent Tee Filter present? ❑ a f yesvVas it cleanec� g ❑ (es--L-
Yes
xQ �t
5. Condition of System:
n
r.
�5ttf
6. System em Pumped By:
Vehicle License
Name Number
Company
7. Location where contents were disposed:
/ 7
Signal re of Hauler Date
__ ...._—..
5ignalure____of--Receiving-- - Facility Date
t5form4.docc 03!06 System Pumping Record-Page t of t
Commonwealth of MassachLlSettS Form 4—System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
All IlA,I v,
i,A, 4)
'k
Type: Emergenc Routine T
Cesspool: No Yes Septic Tank: No Yes
Date of Pumpinq: Quantity Pumped: 1000 Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
ry
011
Contents Disposed at:
Ac.PAj
.3
Pumper Sig
Date: nature:
Condition of System/Other Comments
Haverhill WWTP
(OD78) 374-2382
Printed oii recycled paper Dep Approved Form-12/07/95
COMMOMeOlth Of Massachusetts Form 4 Systern Pumping Record,,,;,,,
Massachusetts
System Pumping Record
1 .
Sygtelm&he� System Location ..............
A
'y 8 X i,',(l j0p:
'11k) 10 1 IV,C)Y, 7),'4f,rd,C3 V, V 0
9
"y
Type: Emergent: Routine
Cesspool: No /I/ Yes Septic Tank: No Yes F21"
bate of Pumping: 91-,)-31 22- - Quantify Pumped: IWO Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to;
Contents Disposed at:
-----------
5
bate: Pumper Signature: C,
Condition of System/Other Comments
I'd lited oil recycled paper bep Approved Form 12/07/95