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HomeMy WebLinkAboutSeptic Pumping Slip - 35 CHERISE CIRCLE 3/23/2016 .........., Orr mono eafth of Massachusetts d _ 3 _ Ci-iy/.f own of North Andover Ij System Pumpilng Record Form 4 DEP has provided this form for use by local Boardd,of Heaalltt h Other forms r using his form, check with your information must be substantially the same as that proved local Board of Health to determine the form they use.The System Pumping Record must bee submitted to the local Board of Health or other approving authority within 14 days from the pumping, a accordance with 310 CMR 15.351. A. Facility information Important:When on t out computer, y Cati g 1. System o Dose only the pu�er, a, key to move your Address Ma 01886 cursor-do not North Andover Zip Code use the return State City/Town key. 2. System Owner. 01 a Name Address(if different from location) State Zip Code City�rown Telephone Number _ Pumping Record Gallons 1. Date of Pumping date 2. Quantity Pumped: ❑ Grease Trap 3. Type of system: E] Cesspool(s) Tight Tank ( Septic Tank ❑ g ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes E] No If.yes, was it clearied? ❑ Yes ❑ No 5. Condition of System: _„ 6. System Pumped By: Vehicle License Number Name 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 -- Date Signature of Receiving Facility Date System Pumping Record-Page 1 t5form4.doc•03/06 , , \ ' ��[]����{��V����|f� m� K���������F»Q����� � � Commonwealth ~~. Massachusetts�u� vU1� | City/Town '�f North Andover �~'� � ���{�/ � (]\�/�� `�/ /���/ u / M ° � System Pumping Record | Form 4 � DEP has provided this form for use by local Boards ofHealth, Other forms may be uaed, 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 nr other approving authority within 14 days from the pumping dote in accordance with 31OCN1R153G1. A~ Facility Information Important:When filling out forms 1. System Location: �)f- p --) 0.�-(,jC on the computer, use only the tab key N move your Address cursor-do not North Andover Ma 01845 use the return � key. City/Town G\am Zip Code / 2. System Owner: ' Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date ofPumping Pat, 2� (�umn�yPumped: Gallons 3. Type ofsystem: E] Cesspool(s) Septic Tank r-1 Tight Tank Fl Grease Trap LJ Other (describe): 4. Effluent Tee Filter present? �� Yes Fl No If vvaeitu|eanad? �1 Yea �� No y_^ �� ' �� �� 5. Condition of System: O. System Pumped By: Name Vehicle License Number /] Stew art's Septic Service Company 7. Location where contents were disposed: wart!s-P-re-treatment Plant, 20 So. Mill Bradford, Ma 01835 °'°""`"'" Date Signat6re of Receiving Facility Date � | 0fom4,dou 0305 System pumping Record'page 1 of � | PC Commonwealth of Massachusetts - - City/Town of No. Andover i�'��„ � OW � L NOI t"fa1A&ANDOVER System In Record u-aPAa raf DNPAR°t°aDPNT 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 CMR 15.351. A. Facility Information ---- Important: cormputer, use ❑-. t ❑�,,, ,ry: ❑ ___ When fillip out 1. System Locatla g y ., only the tab key Address to move your No.Andover _ Ma 01845 cursor-do not City/Town State Zip Code use the return key. 2. System caner: - - — -- Name pP" Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record . ,.. 1. Date of Pumping - - -- 2. Quantity Pumped. p g 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- � y 6. ,,Snytem Pumped By: Name _ Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: --St�wart I s Pre-trey t Plant, 20 So. Mill Bradford, Ma 01835 ignature o - aau"ter- , Date lf 1ph (j Signature of Receivi F tlity Date t5form4.doc•03/06 System Pumping Record-Page 1 of 1 1 ij} �R, 3� �It' r'�'!i,3 I, '• •! 1 r"�''' � +J •,� d 411 n p,'r,' �'9 \. ''", %I'i yrY" i �4, �ly �Y,lt�' ' • 'I'' ;!'(,',•,.�, V4,t J';;��I,�,�,t ,UI'}I�,�'"1.,;+'n:c+' ;; JY"y"".'Jr^r'.l;r;��, � ' V1}+,yr, •, ti d a� pro'vide Y, 011110006 d jhl� form�for uuo by IQ061 Boards of Hey ith, The RpCOJC rv_ � be xUb I( ed to the (ooal•E3oard of Health or others .4tt ' . � .,,,,l;,�,r'.,•,r.:;;.'f•,.,, pprovl ty ,lnfrrion tl l tm f,'TWr�n fuunq out 1 System,LocaUon h'(h0 tab kv Y l 0 to mova curve'do np► t" 1 ��'1 ✓°�lr /p �' � ' 'ua,'lh�'rptum y ;,•,,,,CitY/rown Slal Yd y •.' i �4�,4�'�p11��;.y i'�i,,•t.P''!',�y',',t,4,1')I!.fir);'",.j�ait t' I r, .. r ® .•�'' 6J ,t ® , P Pde SYslem wner,•'v' PI; � ' •.�" �1;1. � �' '�i�'"tr � Jp�'1'•„{'i'r'e,.,{,11i;"ir1`••v' /1�,(;'{•, '. � � i '��:,'''Il'r''y•J.;"'!f :j, �'N8rf10 ��4`+'; I'"•'';"l1°�';f, v 4.. /•�? -- ;N _"..Add raaa(I(Meronl ran bcatJon) t i,i,,i.f. ,.,; ,•,l � yyPf I' Tai®phone Number r � , Y�'��, • ,(p°+q/ 1/ 'y1 [pry �pq)/y1{/yj+ _d '`J+ M '�!�*wrv�,�+.wbr,"�r i .f•�I,111��G�/y,��rW�Y\ Wi + ���q^y• �1�� 1�•1' tj r /tr♦ >,�/.,I' �,1/r rr 11+i4r;JliG,/��f1+vl,lr ,,: � r of Pum Da plug ' Dele 2.'Qo' * Pumped; /5- C? ' TyP® P�.>5y3161Ti••'; �r � �' Gailon� ' l Cesspool( eptic T ank Tight Tank :i' Effiuo.n,s T�® Plit®CppM,rpsry j.r•y i.L� 'ay,;r„"�j�!'!',,t.�J(Ihl;rvii Y ®t�,�/ If Yes, was f cIoahed? •�• s I ❑ Yes o IM, Q ot$Xf. jp •. , h. rte`''+ �hfr�M(J�, rJll1 i I."—, in,ll tl.f�/ 'rr � • '� `�/^Y ,ti 4� }�4 t�/!`;41}l,yfw•j'�I Y�/ilt I�r�j,!;l;h�`�1�,1�Y.'I��l"�"i'�i't,','.'. � � / �//J/q � � SY ALS'M!P 'roped 8y;" 11 p 1 10 b®Numbet , ,�':: r. .i, i ' 'i,w�� /,,:1' ! �•',h}�Vy}/I� '' 1 4'�/'•�I{�'y/yg,','I�'1�,yY.J,1� J ( �1�1V r!�'nri'� r;�, `,r.;• ,,;t`.,',i, L'oc on.'whl®7r a,r�4':;. r concents,wQC®•dl>gposed; J�,rf�,i '7,�r 'i ryl, ♦ + • YI �� r Yet , „ �, .. •� .Jet.�. ,,�/"'I '.,',%i.,15,'�;',�,;Ilp';;�r� ,.r i+IV��r ,"�� P!'' ,"(. - '� ` �,'. ,,•. .;;/1�.:"r,1. � ;;1'r�1�J,, �;�.."��t'W�l i•".�i,.' 'y, `'�,i: 4 ,4 H i✓, ,,,t1�'1'rt.,�4�'I�YI•'r,'�',•l��pr,,,t't1i�.'W'Y.1!,Q,i•'J'"" , �,Y�,1�, : �• na,huo pl 8V14(�t`F.1r�;v,;;,•,r.4•„ �: � �� ht#pJNr�w�,mass,gov/deph�r�(er/approvaJsJl5(orms,hlm# o®le Inspect l5f0MA doer SYclam P4unpinp Record p;ye TC7wN,Al+`Tr(7Tf ANDOVER SYSTEM PC3IvIPING RECORD DATE , SYSTEM OWNER&A.DDRESS SYSTEM LOCATION DATE OF PUMPING " '• .L• QUANTITY'PUMPED. f CESSPOOL NO YlsS SEPTIC TANK NO YES r NATURE OF SERVICE;;,RQPT,�B EMERGENCY OBSERVATIONS; . C300D CONDITION FULL TO COVER H, AVY GREASE BAFFLES TRACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLM CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY COMMENTS; CONTENTS TRANSFERRED TO ... � 1 , m�ei t�,�* 9"A V y m. rp SYSTEM Y e B 1`boa RECORjo 1)ATV: A R - YSTEM IL GC'ATION (examples left front of house) . OF PUMPINC: ... .. QUANTITY PUMPED , ) i:tiyl'C7UL: NO YES SEPTIC TANX. NO YES NATURE ®PSERYICE; ROUTINE X EMERGENCY UHS RVATIONS.- x C COD CONDITION FULL TO C©vrk HEAVY GREASE 13APPLES IN PLACE ROOTS I LEACHF'IELD RIJHBACK C-XCESSIVESOLfDS FLOODED SOLID.3 CARRYOVER r!7';HRR (EXPL.AM) il,s*rcim PUMPED BY.- u a !a �'uslwlr-,NTS: I'RAMSPCIItRE0 TO.,