HomeMy WebLinkAboutSeptic Pumping Slip - 50 HAY MEADOW ROAD 3/31/2016 Commonwealth of Massachusetts
City/Town of
d NORTH ANDOVER
System Pumping R ecor /�J
Form 4
DEP has provided this form far 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:
When filling out System Location:
forms on the
computer,use
only the tab key Address
to move your (W q .
e
State
cursor-do not Zip Cod
use the return City[Town
key.
2. SystT Owner.
Nanf6
-widr-,e--s-s-(�(d-iff-e-r--e-n-t—f-r--o-,m--location)-- - ,
- *
CilFrTown State Zip Code
Telephone-Number
-
B. Pumping Record
2. Quantity Pumped:
1. Date of Pumping Date Gallons
3. Type of system: E] Cesspool(s) Z,Ser' c Tank 0 Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes
T--No If yes, was it cleaned? [_I Yes 2-'Nr6-
5. Condition of System:
/v)Z)
6. Sy �m Pumped By
N ame Vehicle License Number
'�OJILN( VVVVT'P
Company--- 40 S' Porter St
7. Location where contents were disposed: Brad fob
dq Ma 01836
9 --3 -2382
Signature of Hauler Date
Signature of Receiving Facility Date
l5form4.doc•03106 System Pumping Record-Page I of I
ff
Commonwealth of Massachusetts
k c.D
rrl i'I
City/ "own of
.._ _.. System Pumping Record NORTH AND
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:
1 System Location:
When filling out Y /
forms on the ' >( �� � r
computer,use
only the tab key Address ,may
to move your c —._ tee'
cursor-do not Slate Zip Cc do
use the return
CilylTovJYS�
key" 2. System Owner: /
Name_._.
Address(if different from location)
State 7i Code
City[Town
Telephone Number
B. Pumping record
'_.7 � ` = _. 2. Quantity Pumped: f .
1. Date of Pumping Date Y p Gallons
°" Tight Tank ❑ Grease Trap
3. Type of system: E] Cesspool(s) ept,c Tank ❑ g
❑ Other(describe).
4. Effluent Tee Filter present? �.� Yes L) No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 4�
� 7 �
6. System Pumped By. /
Name Vehicle License Number
Company
7. Location where contents were disposed:
__ _ . a_ d_
NOrth -.
Signature of Hauler Gate
Signature of Receiving Facility Date
15form4.doc.•03/06 System Pumping Record- age I of t
Commonwealth of Massachusetts
ity/Towrr of �'`N l;��I€��r�� D
System Pumpi"g Retard NORTH ANDOVER
Form 4 �'
DEP has provided this form for use by local Boards of Health.Other forms may be used,b t the
nformation must be substantially the same as that provided here.Before using this form, epkly P°tl AINDOVE11,
local Board of Health to determine the form they use.The System Pumping Record must su ut d .a
the local Board of Health or other approving authority within 14 days from the pumping i tit"I' � B I�
accordance with 310 CMR 15,351 �
A. Facility Information
Imponanh
When filling out Y cation:
forms on the -.(J. ,,
cornpu(er,use stom o�✓ l" 1, �C�.l o W
to rnove your Address
use he relulirnl Gnylro"ti SL:nn by Co 9e
kuy. 2 System Owner-
Narne
Address(it different from location)
GityrTr wn thole Zip Gode-- ,
1-1 l C7. fit))_ 1111.f-5
Telephone Nurnbe.r
B. Pumping Record
t Date of Pumping n�t�i l 2. Quantity Pumped r-
y311
3, Type of systern (_J Cesspool(s) IeSeptic Tank f ] Tight Tank (-a Grease Trap
Other(describe)
rt Effluent Tee Filter present? f ; Yes (,f/No If yes,was it cleaned) (,_] Yes (, Ncr
5 Condition of System.
Na stern Pumped By
s
�
�f (ACi Vchuae L.icchrr rWrm
tSrer
0 ,.��
r.drn �., t J fit' o d I r-o(� y) t�1�,
ny
7 Location where contents were disposed
'North Andover, MAC.
Signature of}lauler r:late ._.
Signature of Receiving Facility Date
f5rou,14doc-03106 System frumpusg Record-nage I of 1
M
M1
Commonwealth of Mos;sachusetts hari A�- ���u ���d�� cor d N .
Massachusetts RECEIVED
System Pumping Record
"r'oWiq OF:NOF�ffl° hdDt"3VE
W ii A:O III DEFL A WMENT
System Owner System Location
___�_...... ...... _-- _ ......_...............
Type: Emergent Routine -
Cesspool: No Yes �._._. Septic Tank: No = Yes
bate of Pumping: ^—� 7w Quantity Pumped: o, Gallons
System Pumped Cry: Wind Piver Environmental,LLC — Permit i#:
Contents Transferred to.
Contents Disposed at: „RM1 �" eater
ol 938
k
Pumper Signature: __.._.._ _
Condition of System/Other Comments
111fin d on fckydedImpel bep Approved Form-12/07/95
Commonwealth off assac usetts
City/Town of ng Recur
System Pumpi
Farm 4
c ry rf
i
p Y �u�tw� IS-fartx�bb���r�0 i
DEP has provided this form for use b local Boards of Health. Other fo "
information must be substantially the same as that provided here. Befo�e �i �6 !�' ," ``l,�er wit 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 filling out 1. System Location:
forms the 50 '11(A C Q, i0 Ln� ` J
computer, use
only the tab key Addrep�ss
to move your f C) C �✓ (f i 1 1
use the return 1 t�
cursor- et urn not City/Town State Zip Code
key' 2. System Owner:
� 1
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping _ 2. Quantity Pumped: oo —
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 [?j'No
5, Condition of System:
0«j
6. System Pumped By:
9
Na e - Vehicle License Number
Company ,;
7. Location where c o nfs were is osed:
��reatm I ant
pswic
yr
Signature of Hauler °`� Date
Signature of Receiving Facility � � �:� Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Cowwrmealth of Massodwsefts "
Massachusetts
,.a taw Pwa r wwa„ �•d, � � � � .. � ,�
System O Owner System tocation
�ypw: prr my Routine
bass @: Yes
Se tank: w Oye.
ate of NmVft:— , � a i � 13 �p Quantity pumped: 1 "' 0 Gallons
System pumped By: Wind Piwr v1rarrrrwrrtrrl, Ile Permit ;
Al IG 0 2 20(h
I�bVVi�,f
I I AL Fll
Date: � m pumper ignatum:
zmatdatiwarn,of system/Other cammos
ep Approved Form 12/07/95
TOWN OF NORTH ANDOVER
SYSTEM PUMPING pECORD
5TEM OWNER & ADDRESS � SYSTEM LOCATION
�, (�X mFla: Icf� from hau5e)
r ,
-4— <
�04 ol
L) \,I,c OF PUMPING
QUANTITY PUMPED
LLU� ti
le " °'
i..5.51'UUl : NO YES SEPTIC TANK : NO YES
MATURE OF SERVICE: ROUTINE tlEMERCENCY
�1I1>f RVATIONS;
COOD CONDITION. FULL TO EVER
HEAVY CREASE BAFFLES IN PL,ACI;
ROOTS LEACHFIELD RUNUACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER 0{T�HER (EXPLAIN)
PUMPED BY:
U M M f:NTS,
UNTI,N'T, TRANSFERRED TO: w �
+
r Wt
Mm4 N 1/iet STENART'S SEPTIC TANK).fib A'aln -c- SERVICE
47
A,14 fl h A nmouor- ' BRADFORDo MA 01835
da �r l
Lie- 1 Gl ® 14 978-372-7471
Iri�"�-�!1 L4 r-
wOF _ )c �
MMMY REPORT FOR TCWN of _�l� r)co k✓e,r
DATE ADEPMS
GA=NS COMMENTS
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