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HomeMy WebLinkAboutSeptic Pumping Slip - 40 OXBOW CIRCLE 5/18/2016 Commonwealth of Massachusetts City/Town of A/0 Y i r . 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 a atlgn: on the computer, ® /1 use only the tab ---- key to move your A re 1 cursor-do not 1 ` use the return key. City/Town State Zip Code rnf I 2. System Own Cr N tab Name Address(if different from location) 6 i l i.�l f :r, uir i J City/Town State Zip Code Telephone Number B. Pumping ec r _ 1. Date of Pumping 2. Quantity Pumped: - Date Gallons 3. Type of system: ❑ Cesspool(s) Deptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes o, 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 x =s City/Town of No Andover x /014 System pi Record Form DEP has provided this corm for use by local Boards of Health. Other forms may be used, but the information rnust 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 ("MR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 40 oxbow cir key to move your Address cursor-do not North andover MA use the return -_-. ___-- ------._. key. City/Town State Zip Code 2. System Owner: rab Panes Name --- — __- �ehun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping cor 1. Date of Pur7lping V a-- te __ -.- - __. 2. Quantity Pumped: GIlons _ _.--------.___-- 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap Cl Other (describe): — ------- -- ---- ---- - ---- 4. Effluent Tee Filter present? ❑ Yes 4 No If yes, was it cleaned? ❑ Yes ❑ No 6. Condition of S Y stemk- u � 6. System Pu m 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 Gate _. -- — ---. ..-- ---- ------- Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of No 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. A. Facility Informati®n Important:When filling out forms 1. System Location- u on the computer, use only the tab key to move your Address cursor-do not No andover Ma use the return City/Town State Zip Code key. 2. System Owner: Name ream — Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Quantity Pumped: bate • Gaflons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap [:1 Other (describe): - 4. Effluent Tee Filter present? ❑ Yes.4 No If yes, was it cleaned? ❑ Yes ❑ No 5, Condition of System: 6. N 7 Nam Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stiewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signal e of Ha"mW, :77== Date c ign,+urtB ceiving FAcility' ....... Date t5form4.doc,03/06 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts City/'Town of No andover System Pumping o r __- 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. Syst m Location- on n the computer, bC use only the tab - - - key to move your Address cursor-do not No Andover Ma use the return — -- ----- — —---- ----- key. City/Town State Zip Code 2. System Owner: __ ----------------- Name /Bhl171 '. Address(if different from location) City/Town State Zip Code — ------------- Telephone Number B. Pumping ecor LA ` �-.. &� 1. Date of Pumping 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [tj"Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): ----------- - -- - 4. Effluent Tee Filter present? ❑ Yes El No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. 591st Pumped By: Name Vehicle License Number Stewart's S_e tip c Service Company 7. Location where contents were disposed: ptes - , ment Plant, 20 So. Mill Bradford, Ma 01835 _ uler Date .eceiving Facility — -- Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 C®r� monwealth of Massachusetts -- - W City/Town of No. Andover System u rn 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. A. Facility Information a Important: f�`j ( �` When filling out 1. System Location: forms on the I¢°MN()F I�k) t f C fl)iOVEIR computer, use 40 Oxbow Clr only the tab key Address to move your No. Andover Ma 01845 City/Town cursor-do not ---------------------------- State Zip Code use the return key. 2 System Owner: �Q r� Panos Name e" Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 5/26/11 2. Quantity Pumped: 1500 Date 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: Good Condition 6. System Pumped By: Bruce Merrill 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 --------------- -- rgnature of Haul --- � -------- - e r Date . w.�_ Signature of R ity- Date t5form4.doc-03/06 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts City/Town of NORTH ANDOVER MA System u in g Recor Form 4 DEP has provided this form for use by local Boards of Heal p6P cord must be submitted to the local Board of Health or other approvin 4 r A. Facility Information Important: When filling out 1. System Location: " forms on the _ computer,use only the tab key Address to move your - >C Jja cursor- not City/Town � State ZI Code use the rereturn p key. 2. System Owner: Name _ Address(If different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping gate 2. Quantity Pumped: \ Gallons 3, Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank � f Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: W " 6, System Pumpe By: � arne Vehicle License Number . � - Company 7. contents were dispose : ,,. �vhere co p Location S+ natu a of Hauler pat http://www"mass"gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc-06/03 System Pumping Record Page 1 of 1 OVER : AS 7 Y, ray Redo"rd SACNUS � 4 RECEIVED , (7EP ho provldvd M14 101 i�r �o �:�ir>I{lod to thu lacy! 8;e,c Er b,(n � •, ., qi IhVi �l�r� IWV' it �+°��� i�!)ri� - A Facility ln(orm�llon sa ^, r1 Owner ; Hvn c i d llo?nV,I ri,mp,l --- I r' 1 , r , 6 Pumpl „ ng �or d Re I 3, rYpe of eyylvm, L7 Cvs9pooi(y� Sap{IC Y©n^ r Q 0',�ar (daacriba�:' EMvanl raa FUIo(p('q)on� > oy n'�, r a� �Q? — 6;l C.on46n 9(9y1, m �` SY @ 1 PvMPN 8y 4) on wherQ oor7lanla'wa(a dl�paseo IY� ' , �:�„^�r„�,-r m�sa.8ov/d�pr`waist/epprOYaJa/Ib/orms.r'.�n,al�saac .. „_ ;�.. ..,, .1,,,.� .. rt •fir; aY V' 4 r*' Y yr r `b, "r',• �+` � r a 'y, r " �i � Y6� t7r n pD•P �'"`'� 4 r s � , 1 ,. �ti+`+ fi �M �!}}�� y� �sd tar •.lt 7 Gr,, a 6 z I,� r)' %rVi y'p n r ; d i�Ylr�'� f►i r2��i 1x � ,n Ifr t'+ t , ' Z '{"� rr11 Q4 �,i pry ,frl,R i�1i"`ftit��tit . DEP has provided this form for use by Kcal Boards of{health. The y tvmPumpinq RI0c r ust be submitted to the locai'Board of Health or other approving author ty, i A Facility Infort0ation r ' riWhen f"illing out 9 ' System Location, fo'"on the g� Coi'nputer,use r- A only the tab key Address C to move your:; curaor-do not "" a✓ �( use the return Ciky/Town State key ; .�' Tip Code 2 System Owner,,, Name --- r. .. -,.•, • Address If dlPfer nt from l ` " ocatlon) FIR—Town State Z1 p Code Telephone Number ,r ut� in card .� Date afi Pum in „ m r p Data 2. Quantity Pumped: Gallons Ype of system: Gesspaol(s) Septic Tank Tight Tank Other(desoribe), Effluent Tee Filter present?• Ye s yes, was it cleaned? { i �m It El Ye .. ' s Condition of System'` Pumped y' 1 { +� f erne yG1 ,7 E 1 I �, M IL Vehicle t.ICen$e Number "yr ` camp y ! :v'rJr � r'.igt,++�trid'Ya! IWI.�'jvi r++rr 1wh a,rr{r+l4,',c:• ..,. Location where coat®nts Werqi dlopased; S natur ®�I Hauler Date htfp 1/wwvv mas's.gav/d®p/wa ee/6pprpvals/t5forms,htm#inspect t5fom14 door 06/03 t Sya em Pumping Record•Page 1 of 1 Commonwealth Of Massachusetts City/Town Of NORTH ANDOVER MASSACHUSET G; = System Pumping Record Form 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: When forms filling out 1. System Location: -- Y forms on the computer, use --- --—= , ---- — --- � cursor e c do not — _ only eta key Address use the return City/Town — — State--- - - Zip_Code key. �r 2. System Owner: ---------- -- _ Name — -- — -------— — --- - r erum Address(if different from location) ---- - -- -------- -- -- City/Town — —----- State — .. J . Telephone Number ....o..., .. a ww. . __... . Pumping Record N11 AY 1 1 2006 - 1. Date of Pumping `�, Date -� — 2. Quantity Pumped i+:/�rvi,wf,i- � � ,�.�: ii i,l..1`1� ,,;I �I_i,l 3. Type of system: ❑ Cesspool(s) f Septic Tank El 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: Vehicle License Numbe — Name --- Company 7. Location where contents were disposed: .�.. ~� _......_ , ( Cl J nature of e r Date „ http://www.mass.gov/dep/water approvals/t5forms.htm#inspect t5form4.doc-06/03 System Pumping Record-Page 1 of 1 WRENr y �5 r r d " e h a AtWdl !l.1.0 Y a TOVVN OF I AmL qfC SYSTEM PUMPING RECORD DATE: -� SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) 1paeA075 IA 4c) ox_6u) CC , DATE OF PUMPING: �11-,)�-6a, QUANTITY PUMPED : J_ :�Lc-) GALLONS CESSPOOL: NO YES SEPTIC TANK. NO YES NATURE OF SERVICE: ROUTINE Z EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: ( ' 1� Nrt� AlMh A l�! der ► , ART S SEPTIC TANK SERVICE 47 RAILROAD STREET BRADFORDi MA 01935 W &e I Lot- I l 979-372-7471 mm OF -�d MOMVLY REPORT FOR WWN OF JoAncyiver /0 59 Xem 3y low �/Ym 400 ,C lot 17 I ~Ll ylCoq k es Dr-1 d o l� 76 7bcxC c,- rZr) ® `/ r " 16)o 0 at exl r