HomeMy WebLinkAboutSeptic Pumping Slip - 81 SAW MILL ROAD 3/21/2016 Commonwealth of Massachusetts
City/Town of North Andover
r -
System p
Pumping r
Foray 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
onthecomuter, y �
filling or 1. System Location: `)61 j
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
VQ 2. System Owner: y
Name
retwn
Address(if different from location)
----
City/Town State Zip Code
Telephone Number
B. Pumping Record ,
1. Date of Pumping / /711 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:
6. System Pumped By
� Yi 1. IC 'v �
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
;ignature art's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
af Iaar �.__ "..w__.; Date
,✓
Signature eceiving Facility Date
t5form4.doc•03/06 System Pumping Record-Page 1 of 1
Commonwealth Of Massachusetts
w City/Town of No. Andover
a System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may b use ; �
information must be substantially the same as that provided here. Before using t s form, check with your
local Board of Health to determine the form they use. The System Pumping Rec d mus submitt d to
the local Board of Health or other approving authority within 14 days from the pu pinc i 1. :
accordance with 310 CMR 15.351. N °NNl^ ��
A. Facility Information ,rvo
Important:When
filling out forms 1. System Location'
on the computer,
use only the tab —— {- s�_-_— ;// key,
key to move your Address
cursor-do not No. Andover Ma
use the return ----- ------- -----------
----------
key.
City/Town State Zip Code
w 2. System Owner:
,, ..
Name
rsrwn
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) LQ/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- -------- ------ —
4. Effluent Tee Filter present? ❑ Yes 061 90 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: °4..1,
6" t m u ed By:
me" ° Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
t Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
— — - — --
Si ur o au,ler Date
Si na re o Receiving Facility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
k City/Town of North Andover
- System Pumping Record
-- Farm 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 t d°ptat date anF.
accordance with 310 CMR 15.351.
A. Facility Information
Important: d(JlN,l C lq,�
When filling out 1. System Location:
forms on the
computer, use 81 Sawmill Rd
only the tab key Address
to move your North Andover Ma 01845
cursor-do not ----_.__._.. -- .._......---._..._._
use the return City/Town State Zip Code
key.
ff(( 2. System Owner:
Narayanan
Name
-- — --
e 0 Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 5/6/11 2. Quantity Pumped: 1500 —
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:
Good Condition
6. System Pumped By:
_Frank Eldridge
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 Ha e Date
w
Signature o R,p eiving acility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts �.���rd,�,������
City/Town of TIC ANDOVER A A lJ TT
System pumping card I ;h� � 1,J =i
Form 4
�Ir:w� l Ilcli�l ��! revl il�
DEf� has provided this form for use by local hoards of Hea ...h. fieefff"Pdff ?h ecord must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out System Location:
lo n.
forms on the
computer,use
a- r r....... .� J
only the tab Y
two move your Y not MAddoest ..���t
9 11
use the return City/Tawn State Zip Code
key, 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record t ., w Al..
Date
1. Date of Pumping / 2, Quantity Pumped: t
Gallons
3. :Type of system: ❑ Cesspool(s) E119eptic Tank ❑ Tight Tank
—FLI Other(describe): --
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
C
6. System Pumpe
d BY:,W me Vehicle License Number
` �r. -
.,
Company
7. ere contents were dispose
,
Location where p
S q ati r of Hauler Date-- —
http:/Avm.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc 06/03
System Pumping Record•Page 1 of 1
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