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HomeMy WebLinkAboutSeptic Pumping Slip - 115 LACONIA CIRCLE 5/10/2016 Commonwealth Of Massachusetts City/Town of North Andover System Pumping Record Form 4 w 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 usiRngcthis dforu check umitted r local Board of Health to determine the form 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 CMR 15351. . Facility information R I,VT.`D Important When 511in out forms Location: yb on the computer, "°� "" g - 1. System use only the tab C ' �w t f R ��i..�VW4 rah.{11,x[ I r i/YII)0 key to move your Address Ma Q kk.��L..�i I �'.I,4,01 886 6 cursor-do not North Andover State Zip Code use the return Cty�own key. VQ 2. System Owner: Name rm= nAddress(if different from location) State Zip Code City/r awn Telephone Number �. Pumping Record a 2. Quantity Pumped: Gallons 1. Date of Pumping Date Cesspool(s ( Septic Tank ❑ Tight Tank ❑ Grease Trap 3. Type of system: E] ) ❑ Other(describe): 4. Effluent Tee Filter present. ❑ Yes ❑ No if.yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Sy� m Pumped By C4 Vehicle License Number Name Stewart's Septic Service Company 7. Location where contents were disposed: Steward s,pry={rea ent Plant, 20 So. Mill Bradford, Ma 01835 date Sign of Hauler ignature of Receiving Facility Date System Pumping Record-Page ,^"" t5form4.doc•03/06 mmwmw�rr�r�rcawr' jle�7%��.wr C 4 dp ommonw lth of Massachusetts JUIN ity/-f ow'1 of Pao Andover ��° �wNt� �°�� r�Tt��tAr�t m m i n r HEALTH ��FP ��'I Fora 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 1 t. key to move your Address cursor-do not No andover Ma use the return City/Town State Zip Code key. 2. System Owner: VQ Name NUn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping cor 1. Date of Pumping 2. (quantity Pumped: Gallons Date 3. Type of system: ® Cesspool(s) ,,{Septic Tank ❑ Tight Tank ® Grease Trap Other(describe): 4. Effluent Tee Filter present? ® YeS/FzrNo 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 01335 _ gnatur of Hauler _ Date a . Sigra ure of Receiving Facility Date t aform4.doc•03/06 System Pumping Record.Page 1 of 1 \ | | /�� Commonwealth of Massachusetts x�ff� - ��� �����l�][][\\�����/u / ~// m'����������/ /(���^°��.� City/Town �� �� � ^ ��/ "n�� �������� System Pumping vecord Form 4 | | DEP has provided this form for use by local Boards of Health. Other forms may be ueed, but the information must be substantially the same as that provided here. Before using this furm, check with your � local Board of Health bn determine the form they use. The System Pumping Record must besubmitted to | the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310CPWR 15.351. A. Facility Information Important:When filling out forms 1. System.Location: on the computer, use only the tab key m move your xuureun ou,enr'do not NoAndover . 010 usome�mm ` - --- ---------- key. cuyoown State Zip Code 2. System Owna ` 411z±J Name Address(if different from location) UF City/Town State Telephone Number B. Pumping Record 1 Date � DuanUty Pumped: � oa� � � Gallons 3. Type cfsystem: El Cesspool(s) Septic Tank [l Tight Tank F-1 Grease Trap n Other(describe): 4. Effluent Tee Filter present? F� Yen P~No If yes, was it cleaned? El Yee El No � 5. Condition of ^ : c f ' J > | ~ � I��� � \Nm�#--� ` Vehicle License Number Stewart I s Septic Service Company 7. Location where contents were disposed: r,yart's P Matrpeot Plant, 20 So. Mill dford, Ma 01835 � | t5fonn4dvu 0806 System Pumping Record^Pugo 1 m1 No Andover J&S Development dba 1600 Osgood St Stewart's Septic Building 20 Suite 2-36 Andover Septic No. Andover, Ma 01845 58 South Kimball Street Bradford, MA 01835 ,'&.3F,,V F,YID") Date Name & Address Gallons Comments 1-May Patter reality 81 Sawmill Rd 1500 Good TOWN u -NIOFITH AnDOVr,j° 2-May Mulcahy 350 Sharpners Pond Rd 1500 Good Hi ALITI DEPAFU ENT Greene 62 Willow Ridge Rd 1000 Good 3-May Lacross 259 Grandville 2500 Good 4-May Rincon 115 Sherwood Dr 1500 Xsolids HG 9-May?Callahn 940 Foster St 1500 Good 10-May"Melerim;1444 Salem St 1500 Xsolids 15-May Diraffel 3 Brenkin ridge Rd 1500 Good Depar ,175 Stone Cleave Rd 1500 Good 16-May Martin 701 Forest St 1500 Good Murphy 16 Carleton Lane 1500 Good 18Way Vandbrgraaf 267 Old Cart Way 1500 Good Solano 2198 Trick St 1000 Rh 21-May Totnicho 115 Laconia Cir 1500 Good keki'42 Cross Bow 1500 Good 24-May Carbonell 1560 Salem St 1000 Good 29-May Thurber 210 Farnum St 1500 Good 31-May Cleary 105 Winter green Dr 1000 Good �"�miwmom�uimmi "VOIE I Commonwealth of Massachusetts "I[I .. 18 X U I City/Town of No. Andover 7�� �� ��� ������� 0���ANDOVER System Pumping Record � � Im� PAS t 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 1. System Location. forms to khe / only the key d p Y Y Adress -- --- - -to move your No.Andover Ma 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: ......" t Name erwn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2, Quantity Pumped: - ��� Date Gal`clns 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. tem Pumped B Name Vehicle License Number Stewart's Septic Service ---------------- ---- Company 7. Location where contents were disposed: .t, art's Pre-treat of Plant, 20 So. Mill Bradford, Ma 01835 -- - . - - - na r b auler Date Signa r Receiving Facility Date t5form4.doc-03/06 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts City/Town of NORTH ANDOVER g_MASSACHUSETTS lug System u in poor Fora 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: Men Pilling out 1, System Location: forms the computer,use only the tab ke y Address H ��L t 1• fibL&I to move your �� �4! ttI CP1����W cursor-do not CI /Town — use the return ty State Zip Code key, , 2. System Owner: Name - Address(if different from location) City/Town State Zip Code --- Telephone Number B. Pumping Record - ---- ------- 1, Date of Pumping Date A/ ! 2. Quantity Pumped: � ' — Gallons 3, Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank Other(describe): 4. Effluent Tee Filter present? ❑ Yes D<o If yes,`was it cleaned? ❑ Yes o 5. Condition of System: 6. „System Pumped B q e � d (Jj Vehicle License Number Company ' Locationwhere contents were disposed- (r C1 . �r t _ l X I atu of Haule Date h ttp: /www.mass, o v cpwer/appl ovalslt5forms.htm#inspect — t5form4,doc 06/03 System Pumping Record-Page 1 of 1 AIDDV �`I.,i,• '' ,i � cr� r�, (� � ;�„IR®C�©�CGI ' M A S S A C H U S E T7 RECOVEr hdr plovidod W; lo,,n ror 00 1'r�rnlllo0 to UtY IQ 1 a"'(: �.r � ' acol 6o • ..� oJiln or CU1 A, Faclllty Inf orm Hon WWI I N w+rt l ,l'r Y''�� I��."1'•"I'r tli,,,'r •, J'L� _,., A4d1 w! (II OUf)rinl rp'n buVon) r " umpin�'R� ard _ OaIP o! PVm' � , Oro 3, rY➢a 41 Fyn lam;.,' � C999 001( ) ,--�--._.__ Sop(!C rBo' ,1� r n Z6 A mVOnl r90 FIIIP(pont? L Yp9 h'p t I, C'oanoo? 1 YES ' • "I''�,�',�6"�`;Co�dl�lon'P(,,;9yJ�m ,� _ •�.�'r .�.,I� ''r'J AIIf�.��fi,�51)!', J.,Y,I(,� '�»,.....w^ ,�,�reyy ,.I'7i17'I. . . . , �, ,, ,,,., )1 r �' y (,� ,I, � i' � IL��ry 1y-��,,h/iC����d��yc•�/4,nll n�'� � on,�rhar�,,DOnlanla'wai,� dl9pospp 9 ,.,, a�l�flP 1 Iblorm9,r:mnin9o+sci , i' �Z. pis✓/' 'q r'r - � f^r�� OVA WFlnv rrl rt ,ti +.� ut� y'rp ,y HU GO td, °}�1, '91 „�''iS, 'I r�d�i�r�."j �J��NS��a�01Y��,yt r�y�1'14u1!I,i,• y� �p+� �i�°� 1 v. D EP ln�l hs�vSltlTth�l!'(��f.�rrtil.�, + pro'vfde`d l�_form for uae by local Boards of , be :wbml ad to t�te.local'Bosrd o(Hval(h or f'umPP 9 Reco(c T, ,r•. •r��' ;'I'q,+2r .,,,, other aPpro ng�aw hbrJ;t�, .. A; aclllly .ln orr �tlon ,'�When'(Ung out 11 System l�QCatlonl �.. ^,Y, 'w+,atrH W11 VW III' ' ( ,;F 4,/L ���I I• ,.�/f � � A F'A �� ,/ �ova�yt�b key addross r�GUtri':i•*°,�t"'I,;r.,Clt1'/Tm v •1',;;!' � VWa , ,i; i .. .�,'' up stem owner '',�;1 ' •'fir,`�r';fl+ i✓,V1 r',, Y��'r1�M,��/.�Y'�,,�r'�1•'Y jl 1 Y14r' II +SI Igv'I,r'Ir 4'Y'{1''t {{y{�\\4, jjj ' w :r, �• '�i��s(I,r', 7; :.j�d'^1"��?'7r��6'if:ir'�4�•r't1v,'uh4d,;;i'ri'(,.,' � P"� f"f�lq,• ,ar} �y I .( .,/ ���� '•I :llU('1I,Fj+b.,41Y r�f4M r'•' '�• � �^ �.".o":j+, .h,.'',„r�,t';�';�i;!•r';rAVdSrd'rI'o7a!'a'+'i('IiIl,'l'��ir,bnrt'.(.�y,a"S I,+,; '"f1 +' � p dINerill licil n o caUon) ..a" , State, AO 1 '" Telephone Number - yr;pumpin :� gt7rd 1 ty.k�ii'^�rr;�l{Il,a)'U1,ryN�i'1�,11%'�rll""• �' #tl y ,l, titlil ,r,.lr+;'I,.�r.+yll,>•e;I;:�:"1' t fC. �� 1��11' qat� o Pump 2 a ry'p , data �u ntl umped: tT7 P,® of,a+ystam,; `';' Cesspools) eptic Tank t Tan "pee P�Iter Yek�Q C iunt? If yes was IC CI ne I ea d? [� Yes ❑ No 4Q3rifr�',�irjl/,�1 N d �Ir�;�ondlv,n'4.fy,;c. ! y , l 111 I'll ~ I'�,r�h1'r 4`r J �hr4ny fJ 11 41/h✓1 art;I+L w., I r11Vn 11 rn I ,.i" .. ...,..✓ . .,a t , 1 y r'� 1 1'{�f11,'�fi�,�'jl',��?:'rllwr;r'+'Ij�ylyr„�I��/ ,, t, ��� ✓' � - �' •!',•1',�;,{,I i?J,��'J,;f��ItJ�i iV,�q i�7ti.n�i,l�4i,{�ti.) Idf p,,;;•i;G'''" , j'YVC�;�Atlrrl{1 ri'4 L���ir�J 1 ,;"111•i' ',,. A(�fT1�POped 6y, ":.^�' ;,''�;` � �\'•;,dV'l4iw ii,'N{,','A lj�l �M 111.\�+,'�'r ' ' 1 4,� ,I �", , can :;:�r':� �,,. •��(�� `�,Y r fir, �, �, :� r ,� J''�;: ,II ,, cJe U +0 Number • ',r' %'i.;,,4,3'yl`+t4 r�rlr;y,Yfr`, , , yty((y�ll i 11 lr 1;u 1 I Y'r,,�,, f " r .. - Y; ; on.whera r� ,1 ..1" '�r�i�,;,t','1,^.,;: �,��� ''lh,.• cor�t�nks,µi�,r,®:dl�p`osed, . �;�.. II'w •:.' BSI I��"'""'''^''I�:,�',""�,� , .� dl�l��' ;�,I,�A`,�r i1. , ,,', '„}:i'rl'�•dP.`•^N.''v',, 1,, �''!�'JY,6�,1 ��t,�: 'i r�l ' ' �'+y1 �G�.:,(r1�r�,IS�'��;',`';��%i':I;p'�;�yr`i(ii1':;.Vn• '�',1li'1'+'� l (',I' F!'' ��, � .'ti�i, / 4•t, (i'�� S "flr�!/.4 "1%ruts �y, ,r�+'' �, ', vlgn4l wq Of Hauls( hklpJNh'rW slg® d®gJw�a�er/approv�Js/t5fvrms,htm#Inspect .. t�(curn4+daa;Cd�Q3 +� ,ti' Syclom Pumpinp Record page 1 .. r RT i� is bl+t 1 is! �� 1 '-•S. �+ �Ct '� �yl!'a, �+J'y,f+,iljltr�i4f r� fL rb, r a 4 Y I Y r,.m r_ DER has provided Ohl form for use by local Boards of Health. The Syst ern puIMp(6 cord`must be subml4ed to the local Board of Health or other approving authority, Aq FaOlifyy Infortjaition ; tm ' rtaent, .. ,;TW 'Mung out 1 :' Syst em Ldcatlon f® on the t , Computer,use a �I only the tab our..: Addres to move youpr CI Mown ; (� Cursor do at use the ratum , tY State Zip Code System Owner Name , r 1 .1 a Address(If dlffarent from loostlon) CltylI own Stet Z! Code e . T®lephone Number +i (,1'r 1®a' WaG/l�'�,Y,l,i.,.� a , h pat r of 2, Qu Data antity Pumped; Gallon f a" r . TYp®41'system Cesspools) . . ,. .. Septic Tank Tight Tank Other(describe), y 41 Effluent,T�e Fliter present?. Yes No' If yes, was If cleaned? ® Yes No . `•, ( � 'I! sy Pumped Syl Llcen;e Number t S yr" rw t ir"W��Irl�r fyl�' l'w1 hY i ly � r ,�r.�' r, w�;i��.� I •I1.1 }I��p111�(, �y�jl U'I1p Ut „.,�,: _ i+pinJ<JY'r(`SV, 1Sr'.Qyii�Y r ,1`jl.i,�4rr+�. j1.:a�• { :7 ' Lo u­tion w n' a ro contents Werq�dlposed, eel co oete h1r l/winrw mass,gov/dep�rvstdr/spprpvalsit6farms,htm#Inspect t5fom►4 door 081p3 System Pumping Record Page t of 1 r ,. Commonwealth of Massachusetts l �R City/Town of NORTH SETTS - System Pumping Record - w Form 4 DEP has provided this form for use by local wards 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 forms on the computer, use System Location: ___ only the tab key Address — .__ .----- ------- to move yourp ,r " r t ,� cursor do not /Town •°a_ -..,.�_ ...., / . ---- --- — use the return City State Zip Code key. 2. System Owner: r" Name -- — -- — — ", ... ., Address(if di rentfrom tocetion) -- City/Town y StateY--- — _ Zip Cade Telephone p — �,,,„„mW"' olwi,1'l Pumping Record 1, Crate of Pumping Date 2. Quantity Pumped: , --- -- Gallons Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): --- — ------ -- -- — -- 4. Effluent Tee Filter present? ❑ Yes A. No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Syst B 6. System Pumped y _ Name � —---- --- Vehicle License Number Company 7 Location where contents were disposed: /Signature of � � uler Date http://www.mass.gov/dep/wa er/approvals/t5forms.htm#inspect t5form4,doc•06/03 System Pumping Record•Page 1 of 1 i T�WN OF NORTH AN-MVEP, -M'T"EM PUMPING RECORI) SYSTEM OWNER ADD SS SYSTEM LOCATION ell,M DATE OF PV NQ:_ �Q Y PUMPED;4 /Sz�a.....o.,.,... ,_. VbSS L; � �....�„ r' sop-dc 1' nk; hJU, YES w NA rVRU OF SERVICE; RounNE bMERUENC'ti' ObSERVA'rIONS; O47D CDND1"I IUN „�.... PUL.L 'rU COVER � HEAVY 4> 4E " Rp�T� _ EA.>PF1,133 IN PLACC, LEA.CHnUD RUNEA `.K EXCUSIVE SOLIDS­_­ FLOODED �. (7LCD CSI YC�Y R, OTKER EXPLAIN aystam Pumped by _ � ,...., �`�;:, , VUMMENTS, SUN I'�PI'I'S rKANsytEKKBD 1'() TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE SYSTEM OWNER&ADDRESS SYSTEM LOCATION NO DATE OF PUMPING QUANTITY PUMPED 31-41 CESSPOOL NO_Y YES SEPTIC TANK NO YES-k�- NATURE OF SERVICE: ROUTINE-,��, EMERGENCY OBSERVATIONS: GOOD CONDITION f FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY 6"o c"d el,44 CONTENTS TRANSFERRED TO jAdl I NORTH TOWN OF . V R. SYSTEM P A PIN 1)ATP: ! " 0-1,Ev W—OW-11—F- -& AD1)R1-SS SYSTEM L.4CATION u� front or house ,e 17 DATE OF F'UIY1T'JNC'. �. QUANTITY 'PUMPCD �". i1100L: NO YES ((ww E pyryv Sys"K NO m �w `MATURE OFSERYICE; ROUTINE EMERGENCY ()Itat?RVATIONS:� r GOOD CwDl�LDlT1C1' t FULL TO COYEtt HRA'Y'Y GREASE 13AFFLES IN PLACE ROOTS I LEACHFIELD ttUMBAC - _ ___ EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER �P;H�'R (EXPL>A.IM) ii-s'I'em PUMPED ay: c v' 1Zv1 ENTS: k ONThPIT I'IZANSf EItRE0 TO: TOWN OF NORTH ANDOVER SYSTEM PUMPING DATE: ' kav , SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:e 1� front of lous e) yAt- Aian DATE OF PUMPING: )t - QUANTITY PUMPED GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: / GOOD CONDITION a FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: Sri " t � I 1 1 � , TOWN,OF NORTH ANDOVER SYSTEM PUMPING RECORD p a 4 e r k I Grt�rj' 5�i �Il �+r I i�r+tl{PS,Il l�,x+:..��i�I.,��,:'.��_W..,'',,t r��ii�,�(7 r I)Vi�d>iI,r hr,✓ S�Y� ..r S__. TEom._��, "L .'. �C. . .. N' .'CAT Y f ..,N (example: left froli&of�...h9e +o use) f °� 4t J � PAUPF-P PIN QUANTITY PUMPED G AL LON I N S YIN� " NO SEPTIC TANK: NO YES 4"Q `4, NA AkRE OF SE P gw EMERGENCY� g �a� I 'r T GOOD'CONDIT16N LL TO COVER$EASY GREASE AFFLES IN PLACE� AC L AC I1 FLOODED ROOTS SOLIDS CARRYOVER OT HER (EXPLAIN) PUMPED, Ys 17 57.aI P1 9 I� y ,ry�P t 4?I ,�, � Y ♦y'4 J S t'y�, rf l� d i +I i � i� �I' a t r CJGJ CJJJ.I.7J/ CJ CJ.:J CJ ;J CJ6J/,3g01 A. .�I CV�Ji-iic.I/(-11"I1JV N4af"!. I"'Hl,7G CJ,7 '... 1�� �o►� �; ZC TAM S 47 RAiLRmD r ® M 01835 Um L/! 979-372®7471 ,n 1 L-,e- HDM OP �. � mcia X ROM FOR TCW CP DAIT ADDRESS �_. J isdo /uvp l7d niy or, . look?� i �—,5f Ic'ic�4 ! - 103 Ck,�,r r ��rY4 / t7 166o 1660