HomeMy WebLinkAboutSeptic Pumping Slip - 145 FOREST STREET 4/13/2016 Commonwealth of Massachusetts
C;ity[Town Of North Andover
S e u fin record
Foam,4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially determine the farm as
hey user The System Pumping using
Record must beesu<bmit submitted o
local Board of Health to determl date in
the local Board of Health or other approving authority within 14 days from the pumping ,
accordance with 310 CMR 15.351. Y
A. Facility information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover Zip Code
use the return State
City/Town
key.
2. System Owner:
Name
Address(if different from location)
State Zip Code
City/Town
Telephone Number
B. pumping Record 00
0 Lx 55,1 2. Quantity Pumped: Gallons
1. Date of Pumping Date
3. Type of system: E] 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. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
ign Date
ature of Hauler
Signature of Recei ' acilitY
Date
System Pumping Record•Page
t5form4.doc•03/06
Commonwealth of Massachusetts
City/Town of Forth Andover
wr
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 farm, check with your
local Board of Health to determine the farm 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 forms 1. System Location:
on the computer,
use only the tab ? 1 4 c
key to move your Address
cursor-do not North Andover Ma 01845
use the return n/To S
yw - State Zip Code
key, City/Town _tab -
2. System Owner:
Name - -
Address(if different from location)
-- .....
City/Town State Zip Code
Telephone Number
B. Pumping ecor
1. Date of Pumping �( / 2. Quantity Pumped:/aX) 0
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 ❑ Na
5. Condition of System:
6. System Pumped p d B
\ y:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
St wart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
, ignat"ure of Hauler Date
Si nature of-Receuara y.....m.° —
g rftt Date
t5form4.doc•03/06 System Pumping Record>Page 1 of 1
Commonwealth of Massachusetts
lugCity/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4 ,
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Q forms on the computer,use
only the tab key Address
to move your I� C�
cursor-do not
use the return CIty/Town State Zip Code
key. . 2. System Owner:
rye o,-, Q� a
Name
ICS Address(If different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 10
1. Date of Pumping . Quantity Pumped: ���
g Date 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; Cd
l
61 System Pump d)By:
Vehicle License Number
( t L
ompany
7. Location w pre contents were disposed:
/e 81T1r11rCy-C41
9
,4ez " W /'/6 —1� —/('�
g at re of Ha Date
http:/twww.mass.gov/deptwater/approvals/t5forms.htm#inspect
t5form4.docr 06!03 System Pumping Record•Page 1 of 1
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TOWN.OYNO'UH ANDOVER
SYSTEM PUMPING RECORD
a
DATE
SYSTEM OWNER&ADDRESS SYSTEM OCATION
Mder4 5 6
DATE OF PUMPIN j., �.&',) > Q
f< C UANTITY PUMPED
CESSPOOL NO q ys S '
SEPTIC TANK. NO YES '
NATURE OF SERVICE;;,ROt INE EMERGENCY
OBSERVATIONS;
GOOD CONDITION PULL TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS"FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY Ivl
COMMENTS,,
CONTENTS TRANSFERRED TO` ''