HomeMy WebLinkAboutSeptic Pumping Slip - 215 OLD CART WAY 6/7/2016 Commonwealth g f Massachusetts to
Town g f North. Andover
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System Pumping Record.
System Owner $z .Address:
Bob Kelley
215 Old Cart Way
North Andover, Ma 01845
Date of Pumpin October 19, 2013
Type of System: Septic tank
Location of sy tem: Front yard
Gallons Pumped: 1500 gallons
System Pumped By:
John Zanni Pumping Co. LLC
5 Hallberg Park
North Reading, Ma 01864
License #: BHP-2013-0067
Contents Transferred to: Greater Lawrence Sanitary District
Date: October 19, 2013 Pumping Technician: RP
This is proprietary and confidential information that may be used only by the
Board of Health for regulatory purposes
Commonwealth of Massachusetts
City/Town Of
System Pumping r
Form
DEP has provided this form for use by local Boards of Health. Other forms r,-ay be used, but the ,mi
information must be substantially the same as that provided here. Before u ing tfiis'forn4t, ch'Ca"ith y" ur
local Board of Health to determine the form they use. The System Pumping�Record must be submitte to
the local Board of Health or other approving authority.
A. Facility Information
' / v i 4 J FwP i 1ur s
••• Y( 'TUYm w ame
1. System Location: Left front of house, right front of hauseeft side of house rig side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
Cityrrown State Zip Code
2. System Owner:_ -
E �t
Name --- - - —
Address(if different from location)
City/Town-- State Zip Code
Telephone Number
B. Pumping ec®r
1. Date of Pumping C Gallo
luantity Pumped: —'- ` —
Date ns
3. Type of system: El /Septic Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe): ---
4. Effluent Tee Filter present? F-1 Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
" b. � Lowell Waste Water
Signature of Hauler Date
t5form4.doc•06/03
System Pumping Record^Page 1 of 1
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Commonwealth of Massachusetts RECEIVED
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y$tI e P
City own of H ANDOVER A I
System in cord � V ANDOVER
Form d N OF t:tT
: p e ea bEP has provided this form for use by local Boards of H mpin
g Record mus,r
t be s ubmitted
to the local Board of Health or other approving authority,
A..Falcility Information
Important:
uss
Men Pilling out , System Lpoatlon
forms on the
computer, e
only the tab key Address --
to move your
cursor•do not ""kw e
,..
use the return City/Town State Zip Code
keY' 2. System Owner:
Name
Address(If different from location)
Clty/Town State Zip Code
Telephone Number
b-. Pumping Record y
9. Date of Pumping gate 2. Quantity Pumped: Gallons
3. Type of system: ® Cesspool(s) aseptic Tank ❑ Tight Tank
Other(describe):
4, Effluent Tee Filter present? ❑ Yes ❑ No If yes,,, was it cleaned? ❑ Yes ❑ No
5, Condition of System:
-1---kv( U Z.
6 ,system Pumped 13y,
X
rw Vehicle license Number
Company
7, Location wh"e re contents were d isposed-
t
Ci
~ Ignature of Hauler pate
http://w Av.mass,gov/dep/water/approvals/t5forms.htm#Inspect '
t5fomti4.doc-06/03 ",', System Pumping Record-Page i of 1