HomeMy WebLinkAboutSeptic Pumping Slip - 30 LACY STREET 3/30/2016 4
Commonwealth of Massachusetts
City/Town of North andover
System in g Recor
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 the pumping date in
accordance with 310 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab ------
key to move your Address
cursor-do not N. Andover _ Ma
use the return City/Town State Zip Code
key.
2. System Owner:
o o �.-
j� Name
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. T yp e of system: ❑ Cesspool(s) ep p tic Tank
F-1 Tight Tank r_1 Grease Trap
❑ Other(describe): -- -
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes a'No
5. Condition of System:
6. System Pump(ad By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's f e-treatment Plant, 20 So. Mill Bradford, Ma 01835
Si��9 nature ay,.,e Date
--- =
U r t
Signature gfReceiving Facility Date
t5form4.doc•03/06 System Pumping Record-Page 1 of 1
Commonwealth lth of Massachusetts
W City/Town of No.Andover
-= System Pumping 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 CMR 15.351.
A. Facility Information up , 'UV E D".
Important:
When filling out 1. System Location: p
forms on the
computer, use t only the tab key Address
to move your )0 NOR')'tt a AM OVER
w�FP tl 1.
cursor-do not No Andover Ma Iii a 1
a CV�Pt
�a.
- ------- ---------
use the return City/Town State Zip Code
key. 2. System Owner:
1A
Name
-- ---------------- — --------
rerum Address(if different from location)
-------- ------ --------- -----------
City/Town State Zip Code
-------------
Telephone Number
-----------
B. Pumping Record
.. : ('1h A)(Y)
1. Date of Pumping Date } 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:
1
a
0 - --
6. System Pumped y;
- (/. .
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
----- -----
ig ture of Hataier° Date
V.
giii-ature of Receivin •Facility - Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
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Syffitem Pumping Record Page i of {
RE(JUVED D
TO
SYSTEM PUMPING RE, CORD APR 2 5 2005
l
� pall AY
DATE:
SYSTEM GOWNED & ADDRESS SYSTEM LOCATION
(example: left front of house)
K.
DATE OF PUMPING:t QUANTITY PUMPED : GALLONS
CESSPOOL: NO YES S PTIC TANK: NO YES
NA O SERVICE: ROUTINE, EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACH FIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTHER(EXPL
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRE D'TO: G.L.S.D Lowell Waste
1.2/L.2L.2hfJ2._ 978"7776455 F ARh1ER PA(3E 01
v� a
I�
SYSTEM PUMPr.NC Co
1'CM UWN�R & ADDRESS )YSTCM LOCATION
(mmPN: Wl fron( of house)
UA I'F OF PUMPING,
.� QUANTITY !'UMf'GD
C.'lis.51'U�J<� �1♦O YES SEPTIC TANK: NO YES
-\TURF OFSERYICE; G ROUTINE EMERCENCY
COLD CUN0111ON, IN LL TO COYEk
kiRAY'Y OREASC
.13AFFl.LS IN I'I,ACI? --
RUO,TS LEACHFIELD RUNUAC'K,,
' EXCESSI-YE SOLIDS FLOO.DED'
5' l0I ' CAR,RYOYER IJ HER (EXPLA.IN)
tip'>'I'LM PUMPC0 pY
CU.%;,I1YIFNT3:
TOWN OF NORTH T OJ VE
SYSTEM E PUMPING COJ
DATE:
SYSTEM OWNER c& ADDRESS SYSTEM LOCATION
/
p 'r (example: left front of house)
�'. 0.x � ...
A
L
DATE OF PUMPING: ... f QUANTITY PUMPED r V, GALLONS
CESSPOOL: NO �„°°'` ry YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE °°°' EMERGENCY
OBSERVATIONS: `
GOOD CONDITION VZ FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
S 1 S T E,1:I P V1YIP ED BY: I /' ;/t�,l✓J/l \, �)
COMMENTS:
a
�.M . A C)F �-1 E A ..,
CONTENTS TRANSFERRED TO:
