HomeMy WebLinkAboutSeptic Pumping Slip - 191 HAY MEADOW ROAD 4/1/2016 Commonwealth Of Massachusetts
W City/Town Of NO.Andever
a System Pumping
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:
When filling out 1. System Loca to
forms on the
computer,use zoat)- –—------------ ---
only the tab key Address
to move your No Andover Ma
cursor-do not — ---- —
use the return City/Town Statelpd�
key. 2. System Ow„pr1
Name -
eNm �• — — ;t AB b p�i b6
i l B a�V @[XA/l �'
Address if different from location)/l”�ke1k iwt ii
----- ---- -------- ------- — ---------
City/Town State Zip Code
Telephone Number
B. Pumping Record
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:
6. S%/q. m Pumped�By:
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
Signature of
Date/
,
Signature of Re iving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Com, monwe lth of Massachusetts
City/Town of V �u
System Pumping Record
Fo rm 4 'J U -
DEP has provided this form for use by local Boards of Health. T em Pumplu Recor must
be submitted to the local Board of Health or other approving aut r Nol'�' �1 A DOVER
W:A-111 DEPART N-r
A.. Facility Information
Important;
When filling out 1, System Location: q
forms on the
computer,use
only the tab key Address
to move your 0 y
cursor•do not CI flown \ _ t
use the return ty State Zip Code
key. 2, System Owner: y
Name l )
Address(If different from location)
City/Town State Zip Code -
Telephone Number
B. Pumping Record
9. Date of Pumping 2. Quantity Pumped:
Datte e Gallons
3. :Type of system: ® Cesspool(s) ❑ Septic Tank ❑ Tight Tank
— Other(describe):
4, Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
SwF
.J
6. y stem Pumped By:
A[ t 4 �
(, a � dw� �, Vehicle License Number
Company
disposed:,
where contents were � � � "� �.�;::� �;-�..._ .�. w �`� .. . , .
Location
... M ..
a,
ature of Hauler`"°�°° °�' Date
http://www.mass,gov/dept water/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record Page 1 of 1
r
Commonwealths of Massachusetts
Q UCity/Town of NORTH ANDOVER
System in cord
Fora 4 4"Ai
bEP has provided this form for use by local Boards of He it ecord must
be submitted to the local Board of Health or other approvi
X Facility Information
Important;
When filling out 1. System Location;
forms on the °ti
computer,use �,
only the tab key Address
to move your y7
cursor-do not
use the return City/Town
State Zip Coda
key, .,
2. System Owner; .-....
Name 1
Address(If different from location) ---
City/Town State Zip Code --_
Telephone Number
B. Pumping Record
1. bate of Pumping Dat6. 2 Quantity Pumped:
Gallons
3. : Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
"*{] Other(describe); _
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes;'was it cleaned? ❑ Yes ❑ No
5, Condition of System;
6, S,.item Pumped By;
!
a e Vehicle License Number
f
Company
7, Location where contents were dispos ;
tU a
o auler Dat —
http:/Amw,mass.gov/depiwater/approvals/t5forms.htm#Inspect
t5farm4.doa•06/03 System Pumping Record-Page i of 1
Commonwealth of Massachusetts
North Andover, Massachusetts
System Pumping Record
System Owner & address:
Kendall Spracklin ,� —,..'.,
191 Hay Meadow Road
North Andover, MA
Location of system: Rear, left side
Date of Pumping: November 1, 2006
Type of system: Septic tank
Gallons Pumped: 1500 Gallons
System pumped by: Service Pumping & Drain Co., Inc.
License : B P®20050649
Contents transferred to: Greater Lawrence Sanitary District
Date: November 1, 2006 Pumping Technician: CC
This is PROPRIETARY and CONFIDENTIAL information that may be used only
by the Board of Health for regulatory purposes
p'-'YS7"FM , .. API RECORD
1),i°i'1;,
SYSTEM L CATION
w- ( Pit". left froof of boos ) .
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w OF P r.
No ' Y S SEPTIC T A tq K. NO Y E
w
NATURE CAP SERVICE; ROUTINE, .....,. EMERGENCY
GGGC) CONDITIOX f ... FULL TO ovr--k
HEAVY GREASE BAFFLES IN PLACE
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER P;HF.R (EXPLAJN)
�YSTEIM PUMPED 13Y a
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