HomeMy WebLinkAboutSeptic Pumping Slip - 36 PATTON LANE 3/21/2016 Commonwealth of Massachusetts ❑ity/Town of North Andover System Pumping Record Form 4 local Boards ealth. Other forms may be used,I but the DEP has provided this form for use by ame as that prow ded here� Before using this form, check with your information must be substantially the s he submitted to determine the form they use. The System Pumping Record mus local Board of Health to ,date in the local Board of Health or other approving authority within 14 days from the pumping accordance with 310 CMR 15.351, A. Facility lnformation important When 1. System Location: filling out forms rms on the computer, (3(o use only'the tab key to move your Address Ma 01886 cursor-do not North Andover State Zip Code use the return CitylTown key. �YQ 2. System Owner: �o Name mean „ Address(if different from location) State Zip Code city i own Telephone Number B. pumping Record 2. Quantity Pumped: Gallons j 1. Date of Pumping Date V 3. Type of system: E] Cesspool(s) S/Septic Tank El Tight Tank ❑ Grease Trap ❑ Other(describe): ❑ Yes ❑ No 4. Effluent Tee Filter present? ❑ yes ❑ No if.yes,Was it cleaned? 5. Condition of System: 6. Systern*Pumped By'. Vehicle License Number Nam ewart' eptic Servi Company 7. ion where contents were disposed: Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835 Date Signature of Hauler Signature of Receiving Facility Date System Pumping Record-PagE 61orm4Aoc•03/06 Corrunonweal-th t = System Pum.jping Form 4 DEP has provided this form for Use by local Boards of Het alth. Other,formes may be used, but the information inUst be substarrtpally the same as that provided hare. SefOre USirrg this form, check with your local Board of Health to determine the form they use. The System Puraiping Record must be submitted to the local Board of H"', lth or other approving atrthority within '14 days,frorn the p ffrnpintf date in accordance with 310 CM '15,351. A. Facility Infonnatio Important:When filling Gaut forriis 1. Systeraa Location: on the computer, use only the tab 36 Patters lane key to move your Address cursor-do riot No Andover Ma use the return uikyll"c>wn _ Stott _._ Zip key. Z r: 2, System Owner: 4,14 Yok.en Nru'rcr ar,�rr Address(If different front location) City/Town State ,'rr)Code _ ---- Folophone Nurnbei B. Pumping Rec.ord 1. IXate Of PLIMpirrg Ili r� ,� 2, Oftantity PUrnp.aed: � iC Crate Q'Illons 3. Type of system: Cesspool(s) Septic Tank El Tight Tank (."rvJ Grease Trap C4 Other(describe): - 4, Effluent Tee cue h ilter present? Kes ] iVo If yes, was it cleaned? Yes s C_� Ala !�. C�,aradrtlon of System: t� 6. System Dumped Cry: Name vehicle License Nurnbor Stewart's Septic Service C,orrrpany 7. Location where c;onh,,mts were dish:)osed; Stew, -t"s Pre-treatment Plant, 20 13o, Mill Bradford, Ma 01335 l3tiutt�rro cf rte.t wing Facility [)at(, --- _ t5forr'n<r.doc-0:3/06 ;7ystem Purnpkng Record>Page I of 1 Commonwealth of Massachusetts -- City/Town of NO.Andover System u i n g Record Form 4 DEP has provided this form for use by local Boards of Health. Other for s may`b°d u°sed, but"the locarl Board of Health to substantially the the fomm they user The System Pufmr ng IR('N"rr',�c��a9C,i W ri your or mtast b 1, t m ted to the local Board of Health or other approving authority within 14 days frorr"i"° RW[M"Mping�dgir accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Loca ion: forms the r computer, use only the tab key Address to move your No.Andover Ma 01886 cursor-do not - — — — use the return City/'I own State Zip Code key. 2 System Owner: Name -------- -- --------------- emm Address(if different from location) -------------- -- City/Town State Zip Code ------------ Telephone Number B. Pumping Record _ 1. Date of Pumping ate '�----..- 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: 6. System Pumped By: game 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 -----.-- Dat -- -- - - -- ------- --- Signature of Receiving Fa ihty Date - — t5form4.doc•03/06 System Pumping Record•Page 1 of 1 r Ir fl,"l'.,� , ! a'I� til •1l"d>r'F${`Sf '1. 1 s, , r ��� "`'a r ' IN itS CC r . � - rill 7 -- r OAP h ( Prarldr d 01 I' )hl1 lolls Iql .�d1111119d1io V11 lot'!I 8clrt: ���! na�Iln pr cul 1 A' Faclllty InfOrr�l�Ilon 111 � _ r r \,1lUrvlrlj Y IIrl, ' „ ,/.' �I ar'/I�I1,11,112/'' �'''� '( �'I'''IY'YI�''(I; ,I", ^";„✓� , r CA"a,n �� r ✓ ,. r '1'1;rlI c; .I I, Oa{a CI Pvmpinq r ! , 1'11„r,I. 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System Owner: r� Name — Address(if different from location) _. ity/Town _ __. State Zip Cade Telephone Number B. Pumping Record 1, Date of Pum in � " ___ _ P g Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes EIV 5. Condition of System: 5. Sy em Pumped By: Name Vehicle License Number Company i 7. Location where contents were disposed: S ature of i4a ul [)ate http://www.rnass.gov/dep/water/ ppravals/tSfonT7s.htm#inspect w t5form4.doc• 06/03 System Purnping Record Page 1 of ? TOIAV t,u' RECEIVED AUG 0 9 2004 JOr b @�'OWNOF�40,Rfll� N I ME � bt)! ` rw C.. 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