HomeMy WebLinkAboutSeptic Pumping Slip - 30 OXBOW CIRCLE 5/18/2016 Commonwealth Of Massachusetts
w City/Town Of No Andover
System Poimping
_ 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 clays from the pumping date in
accordance with 210 CMR 15.351.
A. Facility Information
Important:When
fillip out forms 1. System Location;-
use only he tab
g � .w.
key to move your Address
- ------- - -..--.. —
cursor-do not No Andover Ma
use the return -- ---- -------- — -
key. City/Town State Zip Code
2. System Owner:
--- - ---
------- -----------
Name ---
reMn
Address(if different from location)
----- —- ---- -- --------------------— --- - - -- -
City/Town State Zip Code
Telephone Number
B. Pumping ecor p r .
1. Date of Pumping �to�- ------- - 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(de;tribe):
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 Sep tic_Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 018;5
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record>Page 1 of 1
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TOWN OF El"i-i "E" jVED
SYSTEM PUMPING
� t:7 IA IE: �, v�c e
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SYSTE NER & ADDRESS SYSTEM LOCATION
(example: left front of House)
I "
f
r
DATE OF PUMPING: C-/3 ` QUANTITY PUMPE ND : �` GALLONS
CESSPOOL: 1O_ YES SEPTIC T K: NO YES
NATURE®F SERVICE: RO TTM4 EMERGENCY
OBSERVATIONS:
GOOD CONDITION + L TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS L,EAC FIEL.D RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O +R(EXPL.AIN)
SYSTEM PUMIE ID BY: Bateson Enterprises, Inc.
COMMENTS:
NTS:
CONTENTS TRANSFERRED TO: .Lan Lowell rite
15 I
' I ,Y�• t I 7 ! 1 5 11,4 iy 5
TQWN OF4NQZTH ANDOVER
SYSTEM 0PUMPTNO RECORD
DATE �:. ..
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
Vrref).
DATE OF PUNTIN 3- ✓ QUANI ITY'PUMPED C
CESSPOOL NO e YES ` , SEPTIC TANK NO �
NATURE OF SERVICE;;,RQ l l? EMERGENCY
OBSERVATIONS;
GOOD caNDITTON° FULL-TO COVER
OOTAVYS GREASE BAFFLES E
C
LEACHFIELD RUNBACK
EXCESSIVE SOLIDS 'FLOODED
SOLID CARRYOVER, OTHER EXPLAIN
SYSTEM PUMPED BY
COMMENTS;
CONTENTS TRANSFERRED TO
V i../ VJ/ 1JJ1 VV�JV JV VJI VVW,A..L ,JIL'/WY91`.1/WWI 1L�lJV1�1". i Ht/L VJ.
A../o ray, 47 I�2CAb S
BRADFORD, MA 01835
r4C4 14, /Q07 978-372-7471
MORM OF
DATE ADDRESS
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