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HomeMy WebLinkAboutSeptic Pumping Slip - 41 CHERISE CIRCLE 3/22/2016 _ (,2ityffown d" 76. q 4� ) Sys n Pumping Record d DEP has pre}vided Rds Wa At use by local Bowds of Health, Other Corms may be used, but the information must be nibstaMially Me some as toot pmvicledl hem, Bcstom using this foam, check with your local Board of He1,,lth to deterrnine the form they uwsro. _Me Systom Pumping Record rru st be, submittr e9 to the locos f.3cawd of t-fo alth or offier approving authority within 14 days iron°I the pumping date in accolvi ance with 000 CIVIR W351, a1, A. Facility Wonriation 4,n the cwn utc r filling out fors 1. c>�y t t"fl t ocatictl-v Inn o rk: w ra 9 use Only tht.trmfa _ .P�_ _ Q, key to move your Addrr ,p . _ c'urscar �do net Cabe the rottarn -,u 2. Sysstorn Owrlw< IVr mol rxrcrr + MCA(ii diffe mfit born locartioir) CSityfi"owu tat< O Z O CWe °I"elu�{�taone f*atirrataa=r 1, 5.. -"1 2. CfL ntity L t a 00te am 3, Type of systc;nv � .� C OSSP aO ) C Septic Tan �,. I f'Ipht.t I�i< I � (.xre a e, frail L,_i C3thof' de crib ); 4. MOM M Te?ex^• Hiter p esiant f ! � Yes �, ,R No lw'yte ;, was it G'leane d L_...� Y?`es El No 5. Conn.Mon of Systou a, t.�l�ttwrtl ¢:rlrf^r>t°ti err; time _ (� ... �\/I:Wcle Hor:n90 Nurober SWWW POP NO; Convoy 1. Location wha vi coat€-nts,were disposed: Mewad a pl�int, ?f.) o,Mill Br acftt:rrd, Ma 01835 w>iyu?tu, Date ,�iyneatt ax of Roc€ivi ae;:Faciiity Date, too WAS ysivni Purn Wnq Record«L'Ne 1 of 1 Commonwealth of Massachusetts - City/Town of North Andover — System in Record 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 CM 15.351. uNmo� 11 1 Important: A. Facility Information W hen filling out 1. System Location: farms on the � �„ ,, -computer, use only the tab key A dress to move your No.Andover Ma 01845 cursor-do not - - - - — - ------ use the return City/Town State Zip Code key' 2. System Owner: Ff � Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record fat .�... ���� :. w - 1. Date of Pumping _p e 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. stemP - — . m ed B .�.� Vehicle License Number Stewart's Septic Service Company q , 7. Location where contents were disposed: wart sere tr eatmen t Plant, 20 So. Mill Bradford, Ma 01835 -- - ---- --- --- � '— A - — (111ur,of H I er Date Signature of�ecei nvi g Faciliky Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 . , 'l* y 1 •V'(��•,�q,�,Al'!)gp�,��r�ltr7��J.tl i i t t'., `) �r r y.'�y: irAC � r}5 , 4,p ;Jlrvit rfS '+It+ ' S t )r�tye y Y"Id tiry7 t w ,9�llu( (J , W COT '+'y.t•yf}' , ,`�(��; �"��{'`" �' l }�I 11.yy d' �'y��'r(6}I��"�p,;�7v1'IP11 rI� MAY.. ,I, ,J�t.,r,rt VW,� J:r'•�y}}d, Nll y"}'i �}ry,Jli,'A"tt. I�} ��,riri.l��4�t)rj//'�' � 01 ;1 ., N,hsi provided jhla form (or uz+e by local E30ards of HeA G ! by oubml ado J�T�o,ISS $t'�t� p� o c r.. kt t thv.locat hoard or Health or other approvl g apt pl�n� ��ec r Ai FaclIIty,,lnfo�fti Don + r .,, Wryi W4 out 1r Sysk�m Locaklon on 0: ;;''aarnpUtor; use,,, � � • ' ? �? only!ho W'Uy Addrasa LO meva yoUI curve:.do nql — ) uia the'io tum ;„r;,, Clty/lown y , •�y 141u, ,t�a,; rr,,, .1 t ',{',I.�fpf,,,;,.,;' 1 ,`'r + r; - .,,•- �P Cede jil i.�r. Aa.J+,;lt i(��tJr,� �i19•,t"� ��V � wner.;r�.,},'{,•; „r 'r ' � , • t,r' ,`)l' rt b,"�'�% :$,'y� f{ A�lir rt�� +tl �� / • td + ii�'•'(�•�,, '�r.'.ti'.� '.',.I•.fry;1,;��� 1 tl, .,y„I� '. t. .•':1:111/,r'iti !'!!j;i�;�,a,?.1�`Neme 1QIi'`� Ir !tJ"tr;If r,,;,6y t .,, i ;1''�I r wl,'�.}r,A�I,,,wr'r' i;yr6l�t�^.��I'J; ;.(• � '�+ , :o•,;j{ � '(r",+1 Q{ f l' 11+,?„ 'r.�'r,Si�Y,r.r'. r.ir ��.,. 990 ,� Addrota(Ildltferonl r m locallan) ,ti. ' Vt�`1101!/Iti ;r .• �ir.';tl ,"/,' VtE1t©' 'TPCOC�9 T®lophono NUmbe( Ill i{�I UCI �,r' tt��fiy':� "p•'���''}!1 ''w i� 1'j;Y.'. I•^"t '�ri%; �u1�),p�.f,l"�'',1r�.y 11 1 }�EtS�'v��'�y't'fil�!iSr�i�htgr,J1iG1 �P14L,1+�'}'l�'r. r �^ N, r .t,tr ti l,.::il•';!•'y1�!) t �ri', ` t Dat Q,f Pumping ` 4 n ty Pumped: mp�nq l7eto 2. 'Qua .0 , �. 1 + � ,, Gollona 31 �Typa pFf system. Cosspool(s) eptic Tank ® Tight Tank Other .,,, "�},"y„� Yr•. 1;!,, 1,,,}r,l,+ )Ilr'�jr�Irh,>♦hr C, .: ' (NQ�, 4 +'• ffiva'+11 'j ' Tet tr�lt�C,pf�sent? � Yes � If yes,'W83 It gleaned? �, tl' )�'.,.ggf,�;}}�',ti�pC�wy fr lyp'"j�(,��t1i��,�+:r��r,''t'�'��y'�:1v(,{1j1I�I�i�tl"i�iY�, r'�• � ,Yes � No ,r „r,.}•',iheyl'��'r�,+ VIIlICvI�dIY®n Q,(.Sy `, nq 11'1G.J'rt 1, � , ' �'Y / Ir•1 ;I++i ,. ,r, ;`}�qh• � "r,44i J,h�"�'�)/1 ,{���`J,i' I„r-,jinr))}',I�r�M r,',r: ,. Ity rl/ sl y' ll+ I;,Jrf I r t(v •,i�YtCJ;��U1r�Ci 4l Tr�l/� (1 Il�'r•'�y'r;f�' y P4impedy, �, jyVah/l10 Ucan+e NUmbor N'r'” ')r+;"^,j?�1,�1���v �;;fJ�'�'• ,1V • .r r i �> 1 ,,, t;,.'rC't, Y'°`�u11 + 'i 1; I I >'.,,,y,r, ' ..1 �r,. •1 t r yvl� r�ti.jµ`,�al' r 4! +r�'�f/�' S ) (}�,' /-T r/'S l ,v,,,{'�•.;ivr,rh ft 4 i ' I'INN Hlil�rf! )�.�)�?.•'rirl�IIJ,�',�1'IA�j y when ,1�� �, �'�� Ir/r i��SlL.yrll(J,L.�,yfrrlJT •,�I,..vi�i�A' ;�j 1,Yr„ r �w.mil, j Yp �edi , t • .,�! '� /,.S!:I�Li�'IN•rla:/i.1F, 'J,���.'i 11 y1';1.(�r�• �11fi 1v'�,r I'o'4,y' 'i, � � ,r ..,- •N"t"�� , ,1' ) Sr ! I .'yrv�� ,111�/',,,II'�.'�'i�f yr�,f i'''I' �' � a • r �•'I • jt�n•"�`.i S'4, . �Yl r��lt ,I�'M,ri.'�'i'1 i,�,;414t Y�.Y•1 ,I� ,. - , .•,.ij';.i;�;/.,',�1���.��1,;?''ll,fey,'�l.�jr/trs���,�J�4�HYVIe(ye;,,,,p,yr� 1"�� 1�' ` � � ,. hftpAivWmass},go'/d® plwa�e,rlspp ova �6(ormslhtm lnspact t5farrrr4 dos O�Q3 ',� Syclom PumPlnq Rocord Page I .. ' r1 v��rr 1 7 ' t •' ' '1 ;.t y..y l.r`Yrt.i. 1 'TOWN PF'NOUH ANDOVER SYSTEM KWING RECORD, DATE ET SYSTEM OWNER&ADDRESS SYSTEM LOCATION r. 2 ..' M6. r DATE OF PUMPINQ �QUANTITYPUMPED CESSPOOL NO Y` S z SEPTIC TANK NO YES NATURE OF SERVICE;:RQyTztgB' EMER®EI CY OBSERVATIONS. GOOD CONDITION � FULL To COVER HEAVY GREASE BAFFLES CE ROOTS LEACHFIELD RVNBACK EXCESSIVE SOLIDS 'FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM P UMPED BY COMMENTS; TRANSFERRED TO CONTENTS �' ���� ' � ' , •� .. TOWN OF _jAr SYSTEM PUMPING REC® DATE: � ' h SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) C �-� DATE OF PUMPING: ``l sA, '6 _ QUANTITY PUMPED : V-50-b GALLONS / CESSPOOL: NO YES SEPTIC TANK: NO YES �f • ROUTINE EMERGENCY NATURE OF SERVICE. J OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTEN'T'S TRANSFERRED TO: . Z- � • � "' , 01 Ir}�ijysrSlC,Mi I I'"1 qr" "P, i rr.,�l rx rl ,/ 1 .y '•., � � r t 1 xi dq d q4� � �nTin7}�7 ,' ll`e, �I 5 ? r .•jia e F NORTH ANDOVER I SYSTEM UMPING RECORD a 1 mm j 4 1'�{1 � `�`v r't '�r141,' t 1 f 9 r�7� �'' t•1 lAl�I 'T '' a �, >✓1 , P7t ti 'CI l,.i� ,+ �. r .a ..(�} « '1', -.4 1 tit..e+ +.'�:� r 1,1 « 1�s»�i Qa a,d,1 r✓kY `t'r�i`<'pe a If{I 6/el a.3 M,AAt t` 1141+ x SYSTEM 0 ADDRESS S F 1' CATION , P ntof ✓.: J. r�!.t..�.F/.�/ 6l (/,ice" / �F',✓ ' .. S'tr� F9 •i.'�Mt�wl�.,4rJ, ' V�.�,.�"���/.1:'�IP•, "', 111},: P �G.. s""�P ar°'.„,�°"✓• W�.. '.�� . n f� 7edl4, rr1} iv,� , r� ji„etwa•;!nhi�'•r ti '�1p1„sy +'ih'� pr t.e '.. � 1Sv r� b• I � i • 'QUAN Ty PUMPED TI NS vo t . �"+•'av .,1 M:, � �x4� t'".Ifr �:.,�i. 11 v �'}� t, t1�r?d,., } .. eI NES SEPTIC TANK: NO YES .;, ,.1" I�{�r•1'a's•'' EMERGENCY e � I 01 15 1�1 X P" f a . L TO COVER 'n+ �E BAFFLES DY PLACE ROOTS ' fw�4 EEACIFTE TTVA�5 EXCESSIVE SOLIDS TODED S OLIDS CARRYOVER OTHER(EXPLA�N� �' 1fi 1 �' F�1` {IxrGyf n J•r�r�, vl � ;� i� Ptr 1 �, ' � � ���� v ¢irs• tl fYi""i,! dlt�,��� ! ' "1i�� 'd �.«t ft :.r rt ���., 1 J NO will IJ { r�"�' {> �. ��.�y �elr r} r. . E�t P�"1*� ,• � uir•:" 1 n'`,i+-'- p �"' �{ I "�ti � 1'1� I}p} Iy �cYa dd x .. `}, a��AA 46✓ 4 �% I � ��� �IrG,� ��i t ril y `�yyj'�`Y�dJ��,�vkt p,iva�•}!� ' t« �1,1� a + .1 .. h � :(. }�31 i`a'Iii44f�I', Iv�4'r'I�{ ���' ''t �f"fi '1�`°I,kJF 11 ��+�+ ;�ft lu'�!«ka�9��"t1�,� v"��5!•:'{� ,.,. .'.3�' � « TO