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HomeMy WebLinkAboutSeptic Pumping Slip - 115 CRICKET LANE 5/5/2015 Commonwealth of Massachusetts - City/Town of North Andover System Pumping Record �.�e, r °ijG Form 4 a: DEP has provided this form for use by local Boards of Health. Other forms may be used lauhe 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 CM 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 01886 use the return City/Town State Zip Code key. p 2. System Owner: Name reran , 'YI Address(if different from location) 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. System 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 Hauler Date Signature of Receiving Facility Date t5form4.doc 03/06 System Pumping Record•Page 1 of 1 Ill ��� li dv a�1 uq 5 0 l IN J it tF '. i (!A � > J t�P� n t �Ct���� F/k t4� t4jV V��r11t F� t �(t,tfV"NVt-V7� r ii�wui' •'.v. I�r���+Yt�t��{h t�l,� Srtl �1I�`�".�ti'�tr t(ry� > t, ,, �... X11 '�lral�ri "'{,i lEp,' ' Y il' W uw• ti I4( I W ornrrivn � ltfi of N�ass�Chussc iyl '��rn'�f TTS y, t�rrtpir � �� ►rd To orm'4` t°Tt I t ¢apt � DEP has provided this form for use by local Boards of Wealth. The System Pumping Record n be submitted to the local Board of Wealth or other approving authority, .- A.. F.a,clllty Information t; • Ith kAdd . Locatlor out - 1, S tem I the r use / .. ob key your , G � o not J CI /Town lum tY State Zip Code 2, sy w�!� }, 1 s, Name -�, Address(If dlif©rent from IocaUon) t, Cily/1 own Stato Zip Code Telephone Number . pumping Record �m 1, bate of Pumping � 2, Quantity Pumped: Date Gallons 9, t 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; Usteme By, Vehicle License Number `r1llC� . Company 7,'. Locatlo where contents were disposed, e 4, Ck �i � ar . fie' � —• /, ,mass,gov/d.e /water/appro,vals/t5forms;htm#Inspect •'{R 06/03 ^ System Pumping Record Page i of I N DC� R S S A H U E I 7 � w. l� �OEP has m.{{0j c � r .,d 71 w m y • 4 al"PU mPIno R®Gard --._ 5 �� -J!,h9r (dascrib©J. E,tflu9nl ia � � T©9 R(Q rgwr7 LM -- . y �.' Sy f�r� P�mpaa By �J�j�.fj� tj w r ;'r !��a on ��naraconlenl�"wer9 c�9�.sac /'� � �'•I ��" , lip U.���f �,`/ '� `�f� / l�1'1;-y/`J �.'/?�" ma� n ;'/tj Or/e�prpva)s/Iblorm9 ��� Commonwealth of Massachusetts - x City/Town of NORTH ANDOVER -- T System um in r ,. Form 4 DEP has provided this form for use by local Boards of Health. The System um r � st be submitted to the local Board of Health or other approving authority. � ,,,,m 'v�,,,,,?;, A. Facility Information �1�'q �. Caul Important: When filling out 1. System Location: TOWN OF i��€aR 14 4 A d�.�(,)V4O-� forms to the computer, use � ..o� .I�i�I . P I f ll f I C only the tab key Address to move your cursor-do not - ! f CG - --- ---- - - --- - use the return City/Town State Zip Code -"- -- key. r 2. System Owner: �mm�`' Name - -- — -- ------ --- - Address(if di-ff erent from location) - - - ------ — - ------------------- City/Town --- ------ State -- -"-- ___ e Telephone Number "--- B. Pumping Record 1. Date of Pumping g Dact — 2, Quantity Pumped: ✓ — ----- „,x 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. System Pumped By: Nam Vehicle License Number 7 Company - -- - - t�, 7. Location where contents were disposed: gnature of H ,IM ' - Date - - ----- -- -- -- http://www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect t5form4.doc-06/03 System Pumping Record.Page 1 of 1 i TOWN OF NORTH ANDOVE p,, SYSTEM PUMP'INQ REC;OJ j) UA I'h SYSTEM OWNER ADDRESS SYSTEM LOC"A110N /fat CJ" � hl) 1-111)"(8 DATE OF PU 1AdQ;� �pl,lANTiTY PUMPED: C0SPOOL; Np YES ,.. . �.�..... ,.. ,. ...... Sdpcic Tank; NO YE;S NA rURE OF SBR.VICE: Wu'rtNE. bMERUI NC'Y UbSERVATIUNS; QOOD CONDITION /` FULL 'W COVER VY , E BAFFLES IN PLACL, 'ROOTS _. �. LWHY[ELD RUNBACK .....,. BXCEiSSIVE SOLIDS �ao PL®ODED SOLD CA YONIER._.,.....QTtfER EXPLAIN Sydtvm Pumped by .... G.. rv�ce� C�UMWNTS, .... CuN ItNTS rttANSr'bRRZu r() �.. . w (,;Yi,�r'NpOilld�:I;V1t1'r'l.'i�tr4fY�+�.Ct'r��CC�:'".+.�,>»U•1lYd".w",.t,,jrit';i'.:°,i.'!a Y .'l�a,;b. ,J+a, •...r .y ;•• � .. � �_ t'� yt �yl r f \r'1 �a'� lr� wp t f {t',ir C1i�4.�'� a {"�`tt t� ',r+3 t 4 �a r1 '�'1 �m.,'m.�.,m....•.,..,.t ....».... 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QUANTITY PUMPED : � �,� ������ GALLONS *~ YES SEPTIC TANK: NO YES r CESSPOOL: NO �,��"� NATURE OF SERVICE: ROUTINE+ ��� EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACH FIELD RUNBACK EXCESSIVE SOLIDS S FLODO DEI9 SODLIIDS CARRYOVER OTHE R(E L SYSTEM PUMPE D BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS NSE D TOD: TOWN OF NORTH AN-DOVER SYSTEM PUMPING R COI7 - 9 WNER & ADDRESS [ SYSTEM LOCATION tit `�7'EM O I (example: left front of house) 1 -.. --------------------- ----- ------ -1- ---- --- DA'Z'E OF PUMPING; 0 QUAN`T'ITY PUM1)ED GALLON'S ('I. NO YES SEPTIC: TANK; NO YES .NATURE OF SERVICE; ROUTINE EMERGENCY U13.SFRVA`T'I0NS; GOOD CONDITION FULL TO COVED HEAVY GREAS[' � BAFFLES IN PLACE ROOTS LEACI-IFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) J tiYSTEM PUMPED BY. '��� � C_'U.MMENTS r � (-:ON'1'T�,"N"I'S 'I'IZANSFERREI) T0;