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HomeMy WebLinkAboutSeptic Pumping Slip - 139 OLYMPIC LANE 6/9/2016 Commonwealth Of Massachusetts City/Town Of NORTH ANDOVER System pin r ; Form 4 DEP has provided this form for use by local Boards of Health Other forms may used,, but the information must be substantially the same as that provided here. Before using this farm, 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, j 7r� I r� , use o move your Address 1 1 key "L1 cursor-do not NORTH ANDOVER Ma use the return — -- key. City/Town State Zip Code r� 2. System Owner: Name - rcnnn - -- — ------ —..._ Address(if different from location) -- -------- ---- -- ------ -- ---- --- — City/Town State Zip Code Telephone Number B. Pumping cord 1. Date of Pumping { 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): -- 4. Effluent Tee Filter present? ❑ Yes ❑ o If yes, was it cleaned? ❑ Y ❑ No 5. Condition of System: 6. System Ping ed By: Name -- - Vehicle - - ( ense Number Stewart's Se tp is Service Company - 7. Location where contents were disposed: Stewart's Pre- reatment Plant, 20 So, Mill Bradford, Ma 0183 Signat Hof Haule- °" � "� Date -- — - Signature of Receiv °' cilit - - -- y -- Date - t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts "11 f b` r ?fi a ', City/Town of North Andover System Pumping Record Form 4 °u WV14111() t' 'm'i I 14[O r a DEP has provided this form for use by local Boards of Health. O Fier 1orrinsbd'LY ' 'd°';° t 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 farm 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: p when fin 1 filling out System Locatl forms on the .^ -- k ,o k..... computer, use " only the tab key Address to move your No.Andover ma 01845 -- _ cursor-do not -------------------------- – — use the return City/Town State Zip Code key. 2. System Owner: Name --- ----------------–----------------- emm Address(if different from location) -- ——---- ------------------— — City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons - - — 3. Type of system: Cesspool(s) .o.....ic.�. Tan ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Syste µ. 6. S s, m. �Pumped By:--- P Name .,, Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment-Flant"-20`So. Mill Bradford, Ma 01835 > nature ofH aide r Date Signature of Receiv',a j Facility Date t5form4.doc-03/06 System Pumping Record-Page 1 of 1 , { 0 �COrd � SE krr, �lYi'l. �1�1�,1, IIN�I, ,I'V�Ii J 'I,CIlr," (��� 0 9 ullw,l�/' � II�1114;4'��j rlilll 'r C i'y; - oeprhfl provldfd 1h1! a e I v blrl l(IUIo d ZTH ANDOVER I 911 -7-JA ,.r.l..�^wlww ^,,,� a ty In(orm�(lon, , r' G '1r�' lll�1 i' ul,rr II� � �, h�dlw! 0 (rinl rs�rf bGaVon) , � _. r r !I Iln� , ' 4 4 pVm p I I Q�19/ (d9 JC11bB�' �Illo( - „'Illi�', ',"i'r T 5Y P w I,� MO �, vnrWhol9,�o�lbn4a I',Q r V�✓i y�'� r ' �''' �r�rna ' , �,,rl,„s olhlv�(y/r!Ir�s'lr•',, rl r � ,� �;z I � parlde el�oilappoyY Ali! j �6/O11' P, mNLn FOCI leg y�Y ('S� 111✓1' k f 1/ ?��GY/�r�`+v�� ✓ ,.wyT f '�jr,u1, �Ary•, '/ "iH, r NOOV Be -R \ �''j�, j�,���,'I�`�I�lp ry '/jyt�,Li,(), l,, , .,• . !r} k!� rq P,ha�l would®d �'E I Is m:fie p, thl� form for use by Ioca#I Soard of�l ealth, The S stem Pumpin� Racor r f,, be submitted to thv local'Soard of Health o other approving author) A Facility Irtf a Wfan Nun9 out System YLocatlon, df,l I..I`r iii nl"sy R on the the tab key 1� j e .•' m Cosnpu 1Y �lddrasffi to move your --do do not tha rotum ,` ;.,City own State p Coda l/1 r41'lir„r�'LI / 1ry. ''1�+rdg r4 nYpp'.��' „p1 •.1��,(•. / r 5)l'+•4i ltlf(, 17 rGlj1 .V stem 4� ne 4r;rl• ,.,��; � ai f"a ! tl�'�/ff,F'''!"::l "t hI„r�a�'? �M1 "�° J�Cldraaa(If dlIIi ri t from location) City own s — - • ,, :, � tat©' -, Z!p Coda , , Telephone Number -- • t , f i 'r•*'jQal'tit ut�"'t/(' Jl/dls,r.J}IZ"!`,Y 44 ;.1 ' "datQ'of Pum in ualo 2, Quantity Pumped; --- Type pf system) Coss ®01 s llons ept ank Tight an „ T k • p s Ic r ❑ rl the (describ®);' a v Effluent Tee PI ter �resent? Yes No (p ❑ If yes, was It cleaned? ❑ Yes ❑ No rt , �i r f� rr' e Ir 'r��• ,yr,; ,:�;,1V}Jlfl„' r' •� � ' .. r h y-• '.'\^•t)� .+r'(�/(V�'I�? 7.' 'd v Iry"}{y r'!a''., .�r',•��� �y��,,N � � .. ._, , r�,,,a'.',ifl Y.."."�Yt:S_',y:•;":aSt.'i+•S'li��,l�4' r -- "�6 sy Pumped By;," "�' L ,I..5114 ",l ,'r:.•,'11 , 1. '' �� \ ' �,. 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