HomeMy WebLinkAboutSeptic Pumping Slip - 170 OLYMPIC LANE 6/9/2016 lugCommonwealth Of Massachusefts
CitYaown
System e
Pumping
Form 4
DEP has provided this farm for use by local Boards of Health. tither 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
the local Board of Health or other approving authority within 14 days from the pumping date in to
accordance with 310 CMH 15.351.
Facility Inf r Pion A.
tmportan$;when
filling out forms I. System Location:
on the computer,
use only the tab ' ;,' /Cw,
Ivey to move your Address
cursor-do not
use the return No Andover Ma
key. City/Town
State TIP Code
2. System Owner:
Name ..
Address(it different from location)
City/town
State dip Code
B. Telephone Number
Pumping cr
1. date of Pumping p ate 2. Quantity Pumped: o uan� ,.
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 Ej � .. -
5. Condition of System:
6. ;S stem P
u
Y mpe, SY:
Name -
Stewart s,Septic Service Vehicle License Number
Company
to—cation wh re contents were disposed:
SteWkt's e-treatment Plant 20 So. 1lAill Bradford i1�a 01335
atu., sole t
..`".•
pate
S no reo . .�
of Re ee ng Facility . w .. .
pate
doc-03/06
System Bumping Record o Page f of 1
Commonwealth of Massachusetts
f UCity/Town of NORTH ANDOVER, MASSACHUSETTS
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 filling out 1, System Location:
forts on the
computer,use
only the tab key Address
to move your ) � E) Ode)t
cursor-do not City/rown � I/ State Zip Code
use the return
key. . 2, System Owner: i
Name
Address(If different from location)
Cltyrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ 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: qtv�
6. System Pumped By:
C C-Ainga
Vehicle License Number
ompany
7. Locatio here contents were disposed:
Signature of Hauler Date
http://%&w.mass.gov/depAAfater/approvals/t5forms.htm#inspect
t5fonn4.doca 0W03 System Pumping Record-Page 1 of 1
411 4
nn o n alth of Massachusetts
E
��. . ity wnf NORTH J
I '
yt em, Pu' mping Record � d�ai� ld)fJ�i
,,form 4
DEP has provided this form for use by local Boards of Health. The S'6rh"k'h1ping Record'mu,,
be submitted to the local Board of Health or other approving authority,
A. Facility Information --
Important;
When filling out 1, System Location:
forms on the ^
computer, use
--..__..._._. - ... . r. ,� 1
only the tab kay Address r 7 � -�• - ✓� _ —..�.r_.._..---..----.- --
to move your
cursor-do not _ �'� "�,����k"L���'�,/,�. y' ✓��° ,
!Town
Clt --�~------__�_
use the return y State
Zip Code
key.
2. System Owner: � �4 .
Name
Address pf different from location) —'-"°'-"��°•----°----------- -- -- `
--
State -
y._ ,✓ / Ziipp.,, ode
Tele hoi
P ber
B. um ping Record _—
.r
<• 1, Date of Pumping 2• Quantity Pumped;
Type of system: ® Cesspool(s) .�.. Gallons
Yp Y peptic Tank ❑ Tight Tank
® Other (describe),
4, Effluent Tee Filter present? ❑ Ye ^ o If yes, was it cleaned? ❑ Yes ❑ No
5, Condition of S!s em:
6• Sy em Pumped By:
ame � Vehicle t.icense ,
.. Number
Company A
7. Location where contents were disposed:
_..._v, ,.,...w ._......
Si allure of Hau Date
http://www,masg�gov/dep/water/ provals/t5forms•htm#inspect
t5form4.doc,08/03
System Pumping Record • Page i of
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RE CORD
DATE:
SYSTEM OWNED & ADDRESS SYSTEM LOCATION
.' (example: left front of house)
DATE OF PUMPING° � M"" �:` � QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK,
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY. .4nOoVer 7e 7 C
COMMENTS:
M.r
CONTENTS TRANSFERRED TOO ✓ ���.
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SWTIC TAM 1Zb ta,�r Sf RAIjAM SrREZT
R/e r� 47 r1�d/�r e MA 01835
978-372-7471
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