HomeMy WebLinkAboutSeptic Pumping Slip - 265 HAY MEADOW ROAD 4/1/2016 �a
ornrnonwealffl of Massachusetts
Cityffown of No andover
wJ System Purnping Record
n, Form
DEP has providec.i this farm for use by local Boards of Health. Other farms 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. Dumping Record must be subrnitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 GMR 15.351.
A. Facility Information
Important:When
art t�a� forms I. � �#em I�a Kati rt: ,
filling �y�
he c om pater, ( 7
use.only the tab
r` _ —
key to move your Address 11
cursor-do net No Andover
use thr�rk*t.�.arr� -- —
key. City/Town State Zip Code
2. System Owner:
r�r
Name
retien
Address(if different from location)
Cityrrown State Zip Code
`rolephow)Number
B. Pumping Record
1. Date of Dumping 2. Quantity Dumped: C�alians
3. Type of systern: L] Cesspool(s) [Septic"I'ank I-- Night Tank [_� Grease Trap
[� Other(describe); -- ---
4. Effluent'ree Filter present? ❑ Yes flf No If yes, was it cleaned? Yes C No
5. Condition of stern'
f
6 System �?urr,�ed By:
Name Vehicle License Number
w tewart's Septic Service
Company
7. Location where contents were disposed:
Ste 's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01335
'c na r � it,� Date,
Signature of . r9vrr7r�Farilrty Date
' ' ..
t5farm4.dc>r.^03/06 System Pumping Record•r'art}ra 1 of 1
Commonwealth of Massachusetts
-- City/Town of No.Andover
System Pumping Record
e r, lad,
l
Form 4 ��in�i���� i^,irz!���l,�fi��;�ti���a�
°�
iiFAP
a
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 from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Locatic
forms on the
computer, use
only the tab key Address
to move your No.Andover Ma 01886
cuis,V, -do not __.______..-.-...____-_
use the return City/Town State Zip Code
key. 2. System Owner:
fi
11
Name _....- --
— ----- ---------------—----- -- -
erom Address(if different from location)
City/Town State Zip Code
Telephone Number
-------------- --
B. Pumping Record '07
1. Date of Pumping pate 2. Quantity Pumped: Galions
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: "
t
w.
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
jSignature a ler Datee eiving Facility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
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DEP,has prdvided this form for use by local Boards of Health, he System Pumping Hec rd must
be submitted to the local Board of Health or other approving au'horny,
�. 4 `lW,1l
iiifyy Informed®n
1 + ,,r i(r NE
he' NT
",.. ,W ri filUng out 9 System L.ocetlon,
forms,on the G r�.
=-nputer,use s'
only the tab key^ Address
to move your '
cursor.do not
Use the return'' citXlTown b State Zip Code
Owner,',,'
Name`'
Address(If different from location) �6
cltyrrown state dip code
Telephone Number
f
UMOIng R ecQrd .�
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W. .A
1 9 D
to Pumping Dal Z (quantity Pumped; aeons
I f�Typ�of system) ® Cesspool($) � Septic Tank ® fight Tank '
Other(describe),
4, ' �Sff cent Tee Plater present?. l Yes, No' If yes, was It cleaned? ® Yes [l No
Ccndlkfon of System
+
Sy am Pumped 6y;
S game Vehicle License Number
.to a-Jr 4�i'F{w.i}r° '.^L: +.�`� tt/.s�• '°. :, .
w r
7, '`Loca(1on whir contents wprq d(oposed;
. . O
x Signature of Hauler \J Date
�_...
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TOWN•S)F'NO H ANDOVER
S YSTElyl PUWINO RECORD
DATE
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SYSTEM OWNER&ADDRESS
SYS'T'EM LOCATION
4 UMPED�
DATE OF PUMPING UANTITY'P 1 � )
CESSPOOL NO YES \ SEPTIC TANK NO
YES
NATURE OF SERVICE; R,QT EMEROENCY
OBSERVATIONS:,'
QOOD CONDITION"�':•'IFULL W COVER
4AAVY GREASE ' " : BAFFLES IN LACE
ROOTS LEACIPIELD RUNBACK
EXUSSIVE,SOLIDS ' FLOODED
SOLID CARRYOVE OTHER EXPLAIN
SYSTEM PUMPED BY ;'
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COMMENTS;
CONTENTS w
TRANSFERRED T',
TOWN OF NORTH ANDOVER
S'YST'EM PUMPING RECORD
m
OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
C
s
DA`Z'E OF PUMPING: . QUANTITY PUMPED GALLONS
(.4'sS1)0 0 L: NO
A/—
YES SEPTIC TANK: NO YES
N-vTURF OF SERVICE: ROUTINE EMERGENCY
O13SERVATI0 NS:
GOOD CONDITION F'ULI_, TO COVER — —
HEAVY GREASE, 1301LES IN PLACE
ROOTS LEACHFIELD RUNBACK
EACESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
Sl'S"I'EM PUMPED BY:
11 N1 I N T S:
CONTENTS TRANSFERRED TO: _ _
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