HomeMy WebLinkAboutSeptic Pumping Slip - 14 PURITAN AVENUE 3/24/2016 Commonwealth
Pumping-City/Town of
System r 19�C`! fb i?f 1"w
Form 4
DEP has provided this form for usezby local Boards of Health. Other forms May� ` ' `�;"'b& 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.
A. Facility. Information
1
Right s de of io I: Left Left ht rid Left/Right rear of house, Left/right side of house, Left/
Y _ s
g g, g o uilding, Left/Right rear of building, Under deck
:. .�� ..
Address
"
y
• �.� \� 1 �'q, t .. * �. �` Fir,
Cityfrown state Zip Code
2. System Owner:
Name
Address(if different from location), 7
r _ .. , . 0
city/Town ' State 4 Code
l
c. c C�,.,
Telephone Number v
B. Pqmping Record �•
1. Date of Pumping Date 2. Quantity Pumped:
Gallons -T
3. Type of system: ® Cesspool(s) El-"Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [J-Mom If yes, was it cleaned? ❑ Yes ❑ No
" 5. Condition of System:
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loco`on„where contents were disposed:
r
�.S. Lowell Waste Water
Signitu I Fe cif Haule Date
t5form4.doc•06/03 System Pumping Record 4 Page 1 of 1
wW
Commonwealth ltl of Massachusetts
:.
- w City/Town of NO. ANDOVER
Systern Pumping r
Form
DEP has provided this form for use by local Boards of health. Other forms may be used, but the
information must be substantially the saute 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. N,„ ,
A. Facility Information
Important: (JN 19
When filling out 1. System Location:
forms on the
computer,use 14 PURITAN AVE. MA4,
only the tab key Address ,d , ,,,
to move your NO ANDOVER MA 01545
cursor-do not - —
use the return City/Town State Zip Code
key. Syster-n Owner:
�raL JASON VINING
Name —
Address(if different from location)
City/Town State Zip Code
------._................----------- --- _.............-
Telephone Number
B. Pumping Record
5/9/1? 1500
1. Date of Pumping - ---- 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 M No If yes, was it cleaned? ❑ 'Yes ❑ No
5. Condition of System:
6. System Pumped By:
JAMES I-1. CURRIER 1179-406
—__. .-- —_ ...._ - - _------. -
Name Vehicle License Number
J's SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
, ..a
5/9/12
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4doc-03/06 System Pumping Record- Page 1 of 1
,rmrmw RECEIVED
uu
Commonwealth of Massa cl'i usefts
city/"ro wn of NO. ANDOVER
System Pumping f4t1 ,d,tOF'Po tl t,1�1 '&O lukl!CttVB i'k
Record C,p
Fora 4 �„ ,.0
V�tiBZ°i� t�f�ek”
DEP has provided this form for rise by local Boards of Health. Other fortes irray 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.
A. Facility Information
Important:
When filling out 1. Systern Location:
forms the
computer,use '14 PURITAN AVE.
— --—— —
only the tab key Address
to move your NO. ANDOVEt CIA 0184.5
—_— __ — _ —— Zip Code
cursor-do riot City/Town
— — State p
use the return
key. 2. system Owner:
r JAMES VINING
Name
rarrn Address(if different from location)-
State Zip Code
Cityrrown
B. 1elephone Number
Pumping Record
9/28/10 1500—
Pumping 2. C�uantit Pumped:ed: ---_
1. Date of Date - — -- y p Gallons
3. Type of system: ❑ Cesspool(s) L"1 Septic Tank ❑ "1"iglrt 1 ar�lc
❑ Other (describe): -
4. Effluent Tee Filter p resent? ❑ Yes o It yes, was it cleanest? E] Yes El No
5. Condition of Systern:
0. System Pumped By:
James FI. Currier H79 406 - _.
Name vehicle License Number
J's Septic& Drain
company
7. Location where contents were disposed:
GLSD _—
SignaturpA Hauler Date
t5forn4.doc-06/03 System f'urnping Record W Page 1 of 1
�a
Comi'nonwealth of MassachUseffs
c City/ 1 own of . ANDOVER
\J
Systern Pumping Record
Form
DEP has provided this fOrl-n for trse by local Boards of Health. Other forms may be used, but the
information must be substantially the sarne as that provided here. Before using this fora-1, check with your
local hoard of 1-°tealth to determine the forrn they use. The Systern Pumping record n"iust be submitted to
the local Board of Health or other-approving authority.
A. Facility Inforrination
Important:
When filling out System Locution:
for rns or)the
computer,rise 1-4 PURITAN AVE.
.-
___
only the tab key A,ctclross
to move your ANI C)\lEl
cursor-do not _ ..... MA 01 845 11 use the return City[Town state
lip C;ode
key,
. System Owner:
JASON VININ
Narne
Addres.s(rt'diffeY°er)t frorro laae;atiorr)
Cit /"town _ ,M
- �,- --
y ate lip Code
relepiaone Number
B. P111MIA119 Record
1. Coate of Purnpinp Date 07 2. Quantity Pumped: 1 5t7() -
Gallons
3. Type of system: [ Cesspool(s) __. Septic`I"ank ❑ Tight Tank
0 Other(describe): .. _ ...
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yeas [_.] No
5. Condition of Sy stern:
Co. System Purnped By:
Benjarnin Shute H79 406
alYl' Vf"r71Cle t,ICenSP,NUY71be1'
J's Septic& Brain
Company
7. Location where, contents were disposed:
G l._D
r
tare of order
Date
t5fovrn4.doc-06/03 system Pumping Record. Page 1 of 1
OWN OF NORTH AN'DOVE,P,,
SYSTEM PUMPINQ
(A
DATE OF PV INQ, �� � Q�JAi�I"�"�Y PIJMPCDe....I
w,. ..,.. ...,.
NA r R
U U CJW MRVtCV:
n
GOOD C HDI'TI()N Frt,JL.t., `T`J COVU
` y BA.PTLE3Ind PUAC , TCAly;afj iuii;�7[!
yorrq Ptamld by _1 C:�� .... ¢? ' .IC ..
SYSTEM PyJ IN
1 -gPTEW C)W(1E-TR & ADDRESS SYSTEM LOCATION
C " .. (;, (example: left front of boust) .
UATE OF PUMPING.- QUANTITY Pump ED / °l✓�F` C%A L L is N,
Nye
%"I,'SSI'C)OL: NO YE$ SEPTIC'TAPIX: NO YES
NATURE OF SERVICE; ROUTINE EMERGENCY
()IIsf RVAT(ONS; s,
GOOD CONDITION. FULL,TO COVER
HEAVY CREASE 13APPLE-S IN PLACE
RUNS LEAC'HFIEL.D RUNBA+C'K
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER =A HER (EXPL.AJN)
iYS'I'EM PUMPED BY:
�'ui1�IPNTS:
TOWN OF NORTH ANDOVER
PUMPING SYSTEM
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
Iq
DATE OF PUMPING. re"61JANTITY PUMPER ;; '' f GALLONS
CESSPOOL: NO YES SEPTIC TANK. NO YES
NATURE OF SERVICE° ROUTINE EMERGENCY
OBSERVATIONS;
GOOD CONLDITION FULL TO COVER
HEAVY CREASE RAF'F'LES IN PLACE
ROOTS LEACHFIE,LID RUNBACK
EXCESSIVE SOLIIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED T1 %�