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Home My WebLink AboutSeptic Pumping Slip - 223 FOREST STREET 4/14/2016 < Commonwealth of Massachusetts = I City/fown of North Andover System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the P information must be substantially the same as that provided h(:re. Before using 1Record`must be check ubrniiied o local Board of Health to determine the form they use. The System p date in the local Board of Health or other approving authority within 14 days from the pumping, accordance with 310 CMR 15.351. A. Facility Information important:When Location: filling out forms 1 System ; on the computer, r � ( , _" .... use only the tab key to move your Address Ma 01886 cursor-do not North Andover State Zip Code use the return Cpty/Town key. 2. System Owner: a Name naum=yn Address(if different from location) State Zip Code City/Town Telephone Number B. Pumping record 2. Quantity Pumped: Gallons 16�i 1 1. Date of Pumping Date Tight Tank Grease Trap tic Tank g 3. Type of system: E] Cesspoal(s) Se ❑P ❑ Other(describe): If. es,'was it cleaned? Yes E] No 4. Effluent Tee Filter present? E] Yes ❑ Y No 5. Condition Of System: 6. System°Pumped By: ww Vehicle License Number ;Name W "wart's Setic Service company " " whn" contents,uuere�disposed: Stewart's P e7:1fe m 7. Lo d. ent Plant, 20 So. Mill Bradford, Ma 018,,35 ° Date ignakwr�"of Hauler Signature of Receiving Facility System Pumping Record•Page t5form4.doc-03/06 gi Commonwealth of Massachusetts pity/Tawn of North Andover System Pumping r ��°�ti,�h,��o- i�l��,��c�w� w �H s ALT F,�,A F0 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 forms 1. System Location: on the computer, -- + use only the tab key to move your Address cursor-do not North Andover Ma _ 01845 use the return key. City/Town State Zip Code Uop, 2. System Owner: lb Name - —- -- remm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record m. 1. Date of Pumping J I 0.- 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes –Vzl No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: �w.w ,, y p y: �iAL � stem um e > - " ---------- Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: ewart s Pre-treatment Plant 20 So Mill Bradford, Ma 01835 — '° Signature of ale r-- ...- ._..... Date Signatur .o R ceiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 �� Commonwealth �u~� ��1��\�/�)��/u / ^^/ {�'f�/� fyJ NA over� �� over �� / / / /� .�� `^ System Pumping R=cord Form 4 OEP 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 fnnn, check with your ' � local Board of Health to determine the form they um*. The System Pumping Record must be submitted to the local Board ofHealth or other i rdv within 14 days ho accordance with 310 CIVIR 15.351. A. Facility Information Important: When filling out /. System forms onthe ' computer _—D L use 4— only the tab key """="x ho move your No Andover y@� � cu�or-do not ----- � ooetbemmm City[Town State Zip Code key. 2. System Owner: jollw 0, Name Address(if different from location) � City/Town State Zip Code Telephone Number B. Pumping Record 1. Date ofPumping Date 2� Quantity Pumped: ddLilons- 3. Type ofsystem: F Cesspool(s) .�� Septic Tank [7 Tight Tank Fl Grease Trap ` F-1 Other(describe): 4. Effluent Tee Filter present? Yee RNo /f yes, was itcleaned? F-1 Yee F-1 No 5. Condition of System: 0. Sys mome/h Vehicle License Number Stevvad'e Septic Service Company 7. Location where contents were disposed: Sb+warƒe Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature o au Date � Signature of ecLiving'facility Date \� ��nn4dm�O300 System Pumping Record^Page 1uf1 � � ! t.'' d fY i��Slr�I � � � ;>1 rl';�.�,VI r��,�iy�� ''�1�4'r,i u�p� �,,{';•k 41 P(vYldrd Ihlr Iplln 17/ p1 1 V�IItIlIOC1 19 Vt I Iqo 116CIIC (,"I r ��G�R��I��, q � �,�� 0 V I n a� ,G: s " �' Faculty ln(o�mllon , is ��'lii'tlYtl�ia'�l'.'ir'/'''�''�;'!,a'IIt.T'vl','i ,'l,• '„�', , � JIIII ------._�_. . �. ,,,,` , 'V'�`.�.1'��'y`'I,1,1'�✓.'Vli'It,''��I,rr�,"',,, 1, �rl/� I r.', .I; '�adl , 4 ulnl torn{ouVon) �,, ,�.,._.... . gyp y/'�`J _� �J /4J �r._• ,./ .. 11 19npn,-111,01"i6,`Pumpin�; ��ord ' 1; It Ill,gl 0010 Q1 pin � �' " �',�. 'YYP1 ,411y�l�omi`,• � C��a�ool�� ' :I:, nC? Y0� p . 1 y ,;j��'iaj7�L''�II"4r� /'p��r'+rt�`r�il,n(,i�{V�d �� l��'I�'i',, �! B1. n'811IC•'a4!(100� !'1 �„a„�,.�W"” w"+ .' 44 ' ,'f I'','4i•'1'�IY�l�l}Y ,'r JI'1(,�y I I JI, ,� fl ,I' `�w'� (R, 1�'/I// / ' a+” who(f q • . ! � �rl; '1','l,'I'�I'ir/r/II'r', ' I,�i II/11Y��1,' I!'�� '',,, ., ,,,•, „ " 11'',!'1 m a 0 Y/ 1 4J'� � dap��lai/bpp�4Ya��/141orma,n;mn�n�oocl i +., r.•�f.. d` rpo pip . x, 6 aFox 'r :tidr"AA; '4'111►'j�J;r` Ilr„��%ly;�•,p' , y, ivI+�+Wf". ,.r DEP,has prkded thls form for by local Boards of Health, The System Pumping Record mus! be :ubmlttnd to the local'Board of Health or other approving authority, A;. Facility lnf®�°mtfan f+riY"n M�g out 1 System Lo'u' tlon; b' tar,usoY cJ only the tab key Atldresffi to move your:. — caizor.do not CI ` rotum ty/Town ; ` State — a ;„,,r d ;;r;:;,d :• Zlp Coda Yr,, System Owner, , ' , "�" '•'+' '' .;1�:.Addross(Ildlffarent from location) --- Stale ZI Code Telephone Number — .i1(u ru�itrJl�J�i1�.11� 1( Pumping +� � � � aalo 2, Quantity Pumped; '�'"� Gallons Type yr System, ❑ Cesspool(s) eptic Tank Tight Tank ❑'+Other(d tt 9 ascribe); 4 Effluent Tee Flita present?. Yos to ,y ,w p If yes, was It cleaned? ❑ Yes ❑ No r • r, Ih Ir 1 +�. L1 41{�+�ondltaon QI d7y�t mr�Y i , 1 rr /4' 1 ' ��✓ I !"�Y'A, -NQ�) I �ryyg W IIM!'1'�l!I ', r ji4 1 f�� r'c ,y, � �. rlVohlcta Llcen>la Number / ✓Y"j� • ✓.,,x � .JY 4{+`. ;^, /°j\U11 t:r\',� Y•yj1{u`�/�ll �y��,�(¢!!r 't t\'+ J '. / .. jr'I^'�H''r�l?Vl+ �w.�}W}'♦.r:,I, 1 J ',.rV lti(.. , f, ..T Lou contents Wert dloposed; �r it i 5 r tL �• 1k+gr '1 '1.' ,. r t;r�W.y,,,,r ., Date fittpJ/4wrry mass gov/dep/watar/a pp rovals/t5forms,htm#Inspect t5forrrA doc,0d/Q3 r Syatam Pumping Record Page 1 or I 0,mmonw ealth of Massachusetts �. ? r't city/Town of NORTH ANDOVER HU T� SYStern w F ire rd 4 DEP has provided this form for use by local Boards of Health. The ystert' tampi g f l � uord ` u, be submitted to the local Board of Health or other approving authori y, �r A. Facility information Important: When filling out 1. System Location: forms on the computer, use __.�,._ _.__G.:!r-- .---� � only the tab key Address '��"" to move your `°" �a vl?(% )ea cursor-do not -- use the return City/Town —�— —_-- Skate Zip Cade key. 2, System Owner: ) Name - �aa A _ Cif t`' ddrsss(if different_.___from_location��)..-------.-... City/Town State Telephone Number B. Pumping Record - 1, Date of Pumping to - -- Quantity Pumped: 2. Q Gallo,ns Type of system: El Cesspool(s) &561 ptic Tank ❑ Tight Tank - "" ❑ Other(describe): ............... 4, Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? �. ❑ Yes ❑ No 5, Condition of System. 5, Sy em Pumped By: CC _ ama Vehicle License Number Company 7. Location where contents were disposed: S�*r' au --— —— Date http://www.mass,gov/dep/water/ provals/t5forms,htm#inspect t5form4.doc,06/03 System Pumping Record Page 1 of 4 1"O'W N 0S rti()K 1 i t`' UA I S,T-El woMF't ,C l'7 6 µ, A16 , ,A TT. aF P .. _ rv..._ .�.. �p rUKb GK 3eRYICY �cc�v'rl� J.. ._ ; k htGittlk:,^t CY'C7pC7 Ct.7NC7!'I'ICIN NVt..;.. (tJ i.;u'ti t.Y, "CO�IVS s4l 1p� .,.. LRACFLOODED KUtv(�,, , f "I'C)WN OF NORTH AN�UUVE'� RE CEVV E D SYSTE PIJMPINQ RECORD DA A t' ��,"T 5 2004 ;YSTEM OWNER & ADDRESS � SYSTEM LOC�TA �c)N 'C� .t �.. H T°",�l t ) .P n M F[ ..._... gaeoo\� C c-) C � 6 velc DA"rF,OF QUANTITY PIJMPED 'SSPOOL: NO YES'. ....._.., Sulatic (`�rak: NO YE:S NA FURL OF SERVICE: ROU'C'INt � NM�;4iC3ENC,'1' > 3tik RWGOOD CONDITION V , FULL 'W COVER HEAVY GREASE BAFFLES IN PLACE ROOTS �..�_ LEACHMELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CAkRYOVER,.._,_.__OTHER EXPLAIN Syntorn Pumpcd by CPO .:. /77-�/ �. . An-?a�qq�l Via. C OMMEN-I'; CON I EN I'S f'IiANSFERR,ED I'0 TOWN OF I SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION mw5 (example: left front of Douse) ` DATE OF PUMPING: _ QUANTITY PUMPED : ," °" GALLONS CESSPOOL: NO YES S j IC T : NO YES v NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACIMELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHE R(EXPLAIN SYSTEM PUMPE D BY: Bateson Enterprises, Inc. COMMENTS: CONTE, NTS TRANSFERRE D TO: TOWN OF NORTH ANDOVER SYSTEM PUMPING DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example. left front of house) w DATE OF PUMPING. QUANTITY PUMPED GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE HOOTS LEACIIFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: t9 _ COMMENTS: CONTENTS TRANSFERRED TO: __