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
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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