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HomeMy WebLinkAboutSeptic Pumping Slip - 53 OLD CART WAY 5/13/2016 Commonwealth of Massachusetts u —_ -- City/'Town of North Andover - System Pumping Record a r N t k�i t"tt"ICI�C�( f 1��tt 4 Farm .4� AJH 91EP.A rMENT 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 CM 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab [,b­-,--.`3 V OC'� r t key to move your Address cursor not North Andover Ma 01886 use the return key. City[T own State Zip Code 2. System Owner: Name reran 4��� Address(if different from location) City[fown State Zip Code " C5 0 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. Syste�rp Pumped By: Nam Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant 0 So. Mill Bradford, Ma 01835 e; n t e of H r Date Rignature of Receiving Facility Date t5form4.doc.03/06 System Pumping Record-Page 1 of 1 ra Commonwealth of Massachusetts - City/Town of North Andover f ,�l�:� � ' 3 /i �' �� �i��w,rl1'N y tern Pumping Record r� , i rr�El,r l���r Mi��l 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 t,� h { 1 key to move your Address --❑ ❑ - . cursor-do not North Andover Ma 01845 use the return key. City/Town State Zip Code VAQ 2. System Owner;, 5 -- ❑ _ __ _ ....... Name mean Address(if different from location) —.... ........ ------ —.._..__ — ..._ _ ...... City/Town State Zip Code Telephone Number --.._. B. Pumping Record 1. Date of Pumping G ❑2. Quantity Pumped: l- Date allons 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. , stem 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 cility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town 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 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. tT'rCUW ,.. ...,., RECEIVED arm E I���t'��u�n D A. Facility Information mportant: Nhen filling out 1. System Location: 'orms on the O O �qOJ e;omputer, use 53 Old Cart Wa ry h q.i D& G"TTI T"a ut/ii.l J d )nly the tab key ------_-----_—_----- o move your North Andover ����� ��������� ;ursor-do not -- -------_---__—_--------- Ma _ 0184_5 ise the return City/Town ------ State ---------- ------ -- ey. Zip Code 2. System Owner: R1� `� Guthrie ------------------------- Name -------- ------------ ------- 6A _Addue�s(if different from location)------------------------------------------------------ ------ -------------------------------------- City/Town State ------—-- ------------ Zip Code Telephone Number ------- B. Pumping Record 1. Date of Pumping 5/9/11---------- 1500 ate — 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: Xsolids 6. System Pumped By: Frank Eldridge --- 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 ------------------------- Sig nature of H uler ----- ------------------------------------- Date - -- Signature of ceiving Facility --- -- — Date ""�'�— --� �---—---- -- �rm4.doc-03/06 System Pumping Record•Page 1 of 1 ww . x Commonwealth of Massachusetts City/Town of NORTH ANDOVER MASSA ED System Pumping Record Form 4 JUN . 9 ?o q,J DEP has provided this form for use by local Boards of Health, T be submitted to the local Board of Health or other approving ant rl t�O ipg must �At_TFt DEPARTMENT A.. Facility Information Important: When filling out 1, System Location: forms on the ,7 computer,use ( "1 ?y � p only the tab key :Address :: `` ` `- A to move your cursor-do not 1 1 use the return City/Town key. State Tip Code 2, System Owner: � ` r Name Address(If different fnm I�cadon) City/Town Stake Zip Code _ Telephone Number — g. Pumping Record _ 1. Date of Pumping ! Date 2, Quantity Pumped: 3. :Type of system: ca nons ❑ Cesspool(s) eptic Tank ❑ Tight Tank �] Other(describe): 4, Effluent Tee Filter present? ❑ Yes ❑ No If yes,"was it cleaned? ❑ Yes ❑ No 5, Condition of System: Ic t3• ystem Pumpe ,)By: me � '"� L� �° �• ,� °„�M� � Vehicle license Number Company L _ 7. Location where contents were disposed, ature of Hauler http://www,mass.go dep/water/approvals/t5fotms,htm#inspect Date ' t5form4.docc 06/03 System Pumping Record•Page 1 of t M Rec'o'rd MAY � )}1y A hog p/orldvd (hl° loan lo! ,,no wy ;ocol 6oar�� 00 I:p �, 1 n f /1 cr 8 � va' (IOdy10 the 10 I OBlC I nOJ,ln p! CI/)Q/ �I OVER A7 Fa ty In(orrrl.allon �TM, PC8 ion: r .. I'o�npn, rr,m0lr f. (:Pump�nq Record . ( 08(Q o! Pumpinp�' v,,l ,�✓ ? ;'':ar'.r, ;--. � l `�C��� �� 'fiYp� PI �yilam � ,. �1:.�•, .. 0999 I( Q,.M P(I Ten., p C r •Q�Ocho�r (deJCfib��: ' Ehlvon( Too, FIJ(0 ! r� �, i ('p(��onr� Yo9 �1 �:jr�r,l•r,r{rf j`�� vi,i)�1,� i np f Yd9 n8) II C 68n80? y . " � � Condl�lon'QC,Byjl m � � e s r r I) '�r!•r• � ;iti'! ' — �S:`,i-��.���I�(,j�r �YJ �j;!' ( '� ;I,� �' '''�•�''.�� YI�1IC1} �..�G-0Ilil h'';,'^.%1, -- on,�v�!af�,,00(llsnla',Wer� dl p ( ,,.. DPfore�alfblarm�.r�mpinq�occ Commonwealth of Massachusetts W City/Town of NORTH ANDOVER System Pumping Record MASSACHUSETTS - Form 4 g 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. t A. Facility Information Important: When filling out 1. System Location: forms on the computer, use only the tab key Address " -to move your ---- - ------------- --------------- cursor-do not �% use the return City own --f--- --� r--- _ _ key. -------- State -------- - -------- r, 2. System Owner: Zip Name rerwn ------- Address(if differe t from "" — ,�&n id ti�rA City/Town— ----------- ------ 1 MAY 2006 State - tt p -----_—_ __ � de -. Telephone Number — —_— B. Pumping Record -- --- 1. Date of Pumping Date — 2. Quantity Pumped: _ 3. Type of system: Cel Gallon s ------- ❑ sspoos) � eptic 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: _.�. �•. Na a ____ Vehicle License Number -- Company ---------------------- 7. Location where contents were disposed: -- ----------- Signyature o- -----`------------- " '/www.mass.gov/d / a r/approvals/t5forms,htm#inspect Dae --- --_-_ -n4,doc•06/03 System Pumping Record-Page 1 of 1