HomeMy WebLinkAboutSeptic Pumping Slip - 200 HAY MEADOW ROAD 4/1/2016 ❑, Commenwea6t.h of Massachusetts
4 CityrCown of North Andover
system Pumping Recc)rd
wY DEP has provided this form for use by local Boards o
f f Health. Other forms may be used, but the
p
local must be substantially the same as that provided here. Before rusiRecard'must be submitted
local Board of Health to determine the farm they use. The System pumping date in
the local Board of Health or other approving authority within 14 days from the pumping
accordance with 310 CM 15.351.
A. Facility lnformatiion
important When
1 stem Location:
filiing out corms � System
on the computer, w
use only the tab r w
key to move your Address �'�n��p( ,d 4''���ey�� ° 1886
Ma p coos
cursor-do not North Andover
eturn
use the r State � � G
CF,t [Town
key.
2. System Owner:
OQ ill h
a Name
❑
Address(f different from location)
State Zip Code
city/ own
Telephone Number _._.
B. Pumping Record
2, Quantity Pumped: Gallons
1. Date of Pumping pate
Tight Tank ❑ Grease Trap
Septic Tank ❑ 9
3. Type of system: ❑ Cesspool(s) p
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
if.yes, was it E] ❑cleaned? Yes No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. vacation where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Date
Signature of Hauler
Signature of Receiving Facility
Date
System Pumping Record Page
t5form4.doc-03/06
COMMonwealth Of Massachusetts
u _ City/Town of CVO Andover
System i
Form 4
/ M
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 frorn the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Locatio❑ ❑
an the computer, y
use only the tab � Y l `� �.,�C ,�.1 -)' ----
key to move your Address
cursor-do not No Andover Ma
use the return
key. City/Town State Zip Code
2. System Owner:
Name
reuan
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping coo
:µ A-�
Date Gall
1. Date of Pumping -0.._. 2. Quantity Pumped:
ns
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:
y
6. System Pumped By:
Name i Vehicle License Numb�r .,
kk
Stewart's Septic Service„'°
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Flauler Date
Signature of Receiving Facility Date
t5form4.doc^03/06 System Pumping Record•Page 1 of 1
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CEP has provided this form for use b y local hoards of He Ith. The System Pumpin Record must
be submitted to the loc
,«_ „
local'Board rd of Health or other approvi �r
r r
ciiity Inf rniation
` r4mkwtant.
4,,�,.VVhen filling out 1''.: System Location
•
forms on the`
,
computer,use',`; W� r
only the tab key Address
to move your
cursor a do not
r
.
use the return Clty/Town St ke Zip Code
key 5 "
ystem Owner r
r, •
Address(if different from location)
City/Town State
' Telephone Number
a umping Record..-
Date-of Pumping Quantity Pumped:
bat
2
Gallons
3, .Type of system: D Cesspool(s) &Septic'tank 0 Tight Tank
C]'ether(describe),
Effluent Tee Filter pre6e'ntT,E3 Yes c If yes, was it cleaned? ■ Yes E3 No
1 r +
5 Condition of S stgm
6 Sy em Pumped Sy:
'
Vehicle Llcen$9 Number
C®mpany q
w
w t ru
7 Location where�apntents were disposed:
:Signature of Hauler; ! bake
y i
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t5fomti4.d000 08103 System Pumping Record•Page 1 of t
{ e
TOWN,,OF NORTH ANDOVER
SYSTEM PUMPING RECORD
1
SS SYSTEM 'TICS
(example: left front of house)
��. 104'.��, ,r,, '. �' !� au:'
I�rrell jl t.,11 A , t'.
f DATE OF PUMPING. QUANTITY XJ PE `aeY0 GALLONS
SSPOOL: NO YES
1 11 1 t�1 1 4
SEPTIC TANK: NO Y
1C . F,S C � �F►GE tC'Y
Y". S®.
klmli S � l S 4
'
GOOD CONDITION V FULL ,�yOVE
�6d hlld�� COVER
V l.'!R
ilWi t�F .;'I 1r
HEAVY GREASE BAFFLES IN P'LAC'E
Il ,
ROOTS LEACHFTELD RUNBACK F a
EXCESSIVE SOLIDS FL ODE r
SOLIDS CARRYOVER T E (EXPLAIN)
F r F#s gn" ,i ja
J+j4 ,55''i
dbS:1 y 1
jr(Mt f �;lai u •
I 11
1�� 1
�}
T S �R
{� ( 5
�I�
�1Iff �
�' 4
TO�TN OF NORTH ANDOVER
SYSTEM PUMPING RECof�-D
llENl OWNER & ADDRESS— --SYSTEM—LO C
ICF (rani of hourc)
)et,)w ln2e-) All SM
J OF PUMPINC, QUANTITY P U N/I P CU
)')I'OOLI NO YES S C PTI C TANK : N 0 Y L S
A I'URE OF SERVICE: ROUTINE E N1 E R C EN Cy
(:R V :\T 10 N S:
COOD CONDITION A— FULL TO CUVE',�
HFAVY CREASE 3AFFLES IN ll[.,�Cb'
ROOTS LEACHFIELD kUNIUACK ,
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O�HER (EXPLAIN)
I LM P U M 1)1 L) B Y ,
I N'l F N TS:
I N'1'5 T) A N S F C I I E D TO,