HomeMy WebLinkAboutSeptic Pumping Slip - 1435 SALEM STREET 3/25/2016 Commonwealth of Massachusetts
City/Town of North Andover
System pumping Record
Form 4
local Boards of Health. Other forms may be used, but the
DEP has provided this form for use by Before using this form, check with your
information must be substantially the same as that provided here. pumping Record must be submitted Lo
local Board of Health to determine the form they use. The System
roving authority within 14 days from the pumping date in
,
the local Board of Health or other app
accordance with 310 CM R 15.351.
A. Facility lnformation
important'When
filling out forms 1. System Location: 2
on the computer,
C I i _-
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover State Zip Code
use the return it own
key.
O❑ 2. System Owner.
Name
umry❑ Address(if different m location)
State Zip Code
city/T own
Telephone Number
B. Pumping Record e1c)
1. Date of Pumping Date 2. Quantity Pumped-. Gallons
3. Type of system-. E] Cesspool(s) zkSe ptic Tank F1 Tight Tank E] Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? E] Yes 0 If,yes,'was it cleaned? ❑ Yes KII.`1 0
5. Condition of System:
6. System Pumped B
�,? �M' — Vehicle License Number
Nam":'
Stewart's Septic Service
C.mpany
7. Location where contents were disposed:
Plant, 20 So. Mill Bradford,,��.Ma, 1835
Stewart's Pre-treatment Plan
ILI Date
S re of H u r
t5form4,doc-03/06 ignature of Wcei"ing i1rity Date System Pumping Record Paq(
Commonwealth Massachusetts rr-'N it / n
—U System Pumping Record 1,0 WN 0 0r tt g
Form NT
®BP ha s provided this form for use by local Boards of Health. Othe , but t e
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 p filling 1. System Locati .
forms on the
out
computer,use -- - - —
only the tab key Address
to move your North Andover ma 01886 _
cursor-do not Cityrrown State Zip Code
use the return
key. 2. System Owner:
Name
remm Address(if different from location)
City/Town - --- - State - -- Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping � 2. Quantity Pumped:
Date Lallans
3. Type of system: ❑ Cesspool(s) Septic Tank El 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. s em Pump d y:
Name Vehicle License Number
Stewark Septic Service —
Company --
7. Location where contents were disposed:
Ilies P o auler Date
Signature of Receiving f=acility Date
t5forrn4.doc•03106 System Pumping Record d Page 1 of 1
`I=i�fJ• a r"+Y.'7i if��t q.' �u..y.,. ryr ..
�' � f 1 a r ..ry�y{G/�p�g•'')y��"4�{pb�q�h ,Y,/1r^,�.,I � � � �� r�
h, I'°.s
OVfwm" , 1 }I�U ) wl.+'' r,\wrr „4,r,: '�. '•' •" �• .r;��';^`:., ';;, ,r �r•�; , '.
l�t'�'t° ''1'''/H•.'' 'r�,�,�'�i":(4'il;^�.'),'�'flrr� ^�L'�v�n1�J"��''11'tf':I„
,:I•, ,r°{t:»r,rr b4,{{ �j:: 'f•r,����1, �r>"+1 vll°' .'f••�.,
!+ lrr,'Ipl7il r;yN/; J.'{/ry.t,'u,,,, I�r�'r 1 y Y y
1 r C�EF?,.has prdvfdsd xhC� i`crm�for use b �a� rt, � � � ���L
y i cAl hoards of Health, 7h System Pumping Record f,,_,
be submt�ted to ttt030cal'6oard of Heal h or other a proyln aauth rlry,
�.II I. 1
A,• Fac11(ty lnfa� �afion
allng out 1,.. S Stem coca J i f ni OF kta l ci a i`Ii ,.
0 I
fi
on� y
tJo ,�,. • �, .,
^;..,may ®tea kay' Ad dross mm ... lyf' 'l • ,
to mono yon � 1C1 ---__
rota of CItY�(own
Tip Colo
!''yry'r�•, .r.,•.��,J..ii l.il� + Sys OM
' �7 �` ,�r. � ,v' �`y f) f7"yi,;;r;�,,p�:4''t;(,,,t ,l•'+`�I�,(MtY r p
,:,'•• , rt '.,j'r I.I.I�1r.l 'rr.r'•I„i,r. Y -
" Addroxa pf dlHoronl from locar
don)
C ky�own
,.. Number �
,
t' um.pl �rd'
ra�X
r" ,• � /�r1,
�r
1. Daof pumping ' Date 2, Quantity pum
ped; Galion
3, TYPE of a slam; o
/ Y Cesspool(s) Septic Tank (� Tight Tank
M other(desorib�),
4 �ffluer%l Tea Flite +'j' r
(pre�sen,t? Xes^� o If yes was It cleaned?
l)..y(;,+ 1e$ Q
1
ni,''
r
r I 14 � `y,.Br� fl,'�14{ 7r�lC�j;!',�11N•1,.;'l°ll r Ir;ly 1 t r ,,�° ) ',,,Yr 6"rr
r y
/.
' •, , #...Li,(u'S.Yr".�Y1!:�"40".f.41.r;t i(,"Ila
lrti; r ,
qq SV
1', ,� ;:'K ^r'•;', •, :.•7l pumped 8y+ r:
/l. .r 4 r7,;y1�7+• �.1•,;" r',\t;•1r
'f1' V'1SiSii';"It Jl� am�l�'t}!,'I!!�j^jF rr I
-yI �l 1 � { j�)'t,fw''(I f Vohlc!®lJcen;®Number
'P t,f , f,' r! !l.X'• ' t ! �Y7�
•'r,J' li� r i'i','1'�Y 1 r!� {%�'•'4''I/f:r r r
.�,:�! ,yr: `,.! " ' r rriw��•.,'�I,w,.IU./+:i ,
r'r vi' xl,;:•I' w �14)
.. •;Y .��i.;;. tio�.l.'�tttr,,,, °',`.Vb4+ 14� +rr 4, { y 7;`•�', f��i S�I "i.,, r ,
.il:,Y; 1,r .I.t�.' �'' on,whe,r`e contents
,r•�4dlppos®d;
fat I�, r 'I��• ''lib. ..
.r. il. 4 7rr�',la r•n, r ;j..^ .rr! U�;''"' 1111
5� �rr t r t,��{t"7.i5°!F,'��.�Jrrli� •'I'%t�l ,(�,},!y, 4,...t,i,t't Vow f i t�,�7 � P,',�0'�p,�/ /� '
+fir.'! t,•��yy� , � � t� ..
;,,. ,.:?,'1 ;,a ;t1'"�,;4,s'i^SIQrIIWIWO(HAUIaf;,S+/;',,rr �;;•w,;'..,,.1.,
ht#pJNrww;Mau gov/dep6vate�/apprQva)s/15forms,
Date
'g P�' �er/approvaJsll6Corms,htm#Inspect
Sytlorn Pum In
D 4 Record Pale 1 ., ,
" '��`'lil�(�',/1,'•,r.lf'�i:L''Sr 1 rSYJwt�71`'�,Irrl�°'"�
' ,�.<"'iii 7„'l•,� r:7;:; � titi''�� 1 1,'. ��
1'5711. �yy :nryr;.r:;'d t Il•!(11, h +t � �. � :�,�
„�.y �'i i,'���,j� ',fiil�[,�'J"719�1'f w'Y.a.1':'.�;•t,.
TOWN w. NOR',. ,lh'lh 6" 200
. .M...,.. ,., U fZF"C.0 HC�r N 0F`NfoR r LI erNl x(::kvPi L
I ,
51'$Fr9WN�1� �I7�155 �Sti_� _M
l/lb h i
N� rUKE UI' 3RY1(✓`�; KUV'rirr� ( w
C�NflI'1'IUIr P'VLL Du L'()vrx
R4AYY QVIA38 — 0�,M65 IN Pl nl.�
>y t rnrrya c v by ..lm.E•k
t't1MM�NT�,
TOWN OF NORTH ANDOVER
SYSTEM PUMPING REWORD
^tit STEM OWNER & ADDRESS SYSTEM LOCATION ^�
(mimple; left front of house)
r
L'' OF PUMpINC, ° � QUANTITY 'PUM PC, D_ "U) �CALL0
Ca,SPOOL: NO � '"ES SEPTIC TANK; NO YES
ATURE OF SERVICE; ROUTINE EMERGENCY
uu..FRV,\TIONS;
GOOD CONDITION. FULL TO COVER
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O HER (EXPLAIN)
i
PUMPED BY;
c U.1 lyl P, NTS;
TIZANS'FEIZIZED 'TO: