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HomeMy WebLinkAboutSeptic Pumping Slip - 47 BOXFORD STREET 6/17/2016 Commonwealth f Mqffjuse t -- City/Town of System Pumping Record Farm 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 Location. on the computer, use only the tab i( w _ — lI key to move your Addr s - cursor-do not _ " use the return — ' _.-_ ---- - �r _ — key. City/Town State Zip Code 2. System Owner: gab Name e wn Address(if different from location) City/Town State Zip Code ------------- Telephone Number B. Pumping Record . Date of Pumping G- 1 - _ 2. Quantity Pumped: - - 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 ❑ Na 5. Condition of System: - ------- ------- -------- - - ----- d 6. System Pumped By: Na Vehicle License Number S 's Septic Service----- -- _. _ -- - ompany 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 Commonwealth Of Massachusetts City/Town Of north Andover System Pumping Record r Forms Y 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 CM 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, A = .. , "-1- .. use only the tab key to move your Address cursor-do not North Andover Ma 01886 use the return Cityrfown State Zip Code key. 2. System Owner: Name rerun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record - 1. Date of Pumping Date 2. Quantity Pumped: 7,S-0 Gallons 3. Type of system: ❑ Cesspool(s) 51/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: 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 Commonwealth of Massachusetts -- w City/Town Of Borth Andover System Pumping 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 fining out forms 1. System Location: on the computer, � . o � y use only the tab �� . � ,, Un � - o- key to move your Address cursor-do not North ANDOVER Ma use the return City/Town State Zip Code key. 2. System Owner: r� e. ��, Name ------------ ietun 7��„'!lln — - Address(if different from location) City/Town State ,gyp Code Telephone Number1 B. Pumping Record _ 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) kSeptic 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: } 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewaft' Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 -- ----------- �nafu e f aulerr Date Si ature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVE5­' City/Town of NO ANDOVER JUN I () ?013 System Pumping Record Form 4 rmvt�i OF NOW)l ANDOVER 114EM:114 DM�IARTMEN I" 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 CrVIR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 47 BOXFORD ST ----------------- key to move your Address cursor-do not NO ANDOVER Ma use the return key. City/Town State Zip Code 2. System Owner: SULLIVAN Name arum ------------ --—-------- Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: D a"fe ;l I�066­6s 3. Type of system: ❑ Cesspool(s) ❑Septic Tank F-1 Tight Tank ❑ Grease Trap ...........—-—----------............. ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? F-1 Yes ❑ No 5. Condition of System: —-—----------- 6. System Pumped By: Name Vehicle U rise Number Stewart's Septic Service Company 7. Location wlIer� contents were disposed: ,RVII Stewart' Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 S tur of ft Date igna ur Signature of Receiving Facility Date t5form4.doc-03/06 System Pumping Record•Page 1 of 1 Rlid:10- JF 11 V E Commonwealth Of Massachusetts W City/Town Of NO Andover P'l AY � System t Pumping Record r,rN«it11-iANrX,V�R Farm 4 .�m��n.l f, i 1 I„i I�i I �a I Iii I i,�,,, A 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 on the computer,,When 10 ~ p filling out forms 1. System �acat„„, .. use only the tab �.. � - --_°^� � � � ____ ________ key to move your Address cursor-do not No Andover Ma 01845 use the return City/Town State Zip Code key. 2. System Owner; V rob --- ------- -------- .WF :. . ..... _.. - - ----- ------ Name --- -------- retwn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) `Septic Tank F-1 Tight Tank ❑ Grease Trap ❑ Other(describe): --- �--`---- — 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6---S„ m Pumped y: l Vehicle License Number Stewart's Septic Service Company --- --- 7. Location where contents were disposed: Stems 's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hau r Date Signature of Re i 'ng F cility Date t5form4.doc-03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of ,n System in Record ?Y Form DEP has provided this form for use by local Boards of Health. T ' rd must be submitted to the local Board of Health or other appraving a tBiP'P 44kT EN A. Facility Information Important: When filling out 1. System Location: forms on the .' computer,use only the tab key Address to move your �� j , cursor-do not City/Town" State Zip Code use the return key' 2. System Owner: VQ LA Name Address(if different from location) City/Town State Zip Code — -- Telephone Number B. Pumping acrd .�., f� 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: (Iyd 6. S tem Pumped By e Vehicle License Number Company .. contents were dispose m 7. Location r ere con f Signature of er Date http://www.mass.gov/dep/wat gr/app'rovals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record-Page 1 of 1 t�f, i Lyl! .'l(„P,�+�•1�•�!1S:; f C0 OAK �yl 7 •JC"� C J Yr . I i:iy,� t ( tIJyA ,/ 11 YI,1, + 5y,,, MA CH pwq / ���1� "yy'f�ylirtiljr5 R ���R " D P has provided t hl�form for use by local Boards of He 1th.'.The:.Systern PUMIRIn Record rn ,yl be submit$®d to the.local Board of Health or other approving authority, A; Fgclllty Jnforri ptlgn — **amwartant;,: yVhan'filUnfl out 1 System Lora li J oh tho' en only the tab key Address to move your do pot, `_., a • � th®rotum Oily, own ., State -- F � , ,'I s �P Code 'Y•i.��y,tie 7V�5, .., :.,:,;;1• s } System OvI .� '• , I brM ' G Address(It dltferent from loostlon) . 4 ^, CltyCrown. r Stet© Z1p Codo Telephone Number Y� u�npj � eG�rd �`r 1 ' Date of Pumping ba!® F ( } 2, QuantJty Pumped; Gallons — 3,"T'ype pf system," Cass ool s P O Septic Tank ® Tight Tank J�ther(describe), 4 effluent Tee PNe 5 re Yes No y� ❑ Yes ❑ No / {p sent? ❑ If yes, was It cleaned? I,Condltlon'or.Sy t ,,,, Iry,�v ! r (�^'" (,p^'•�J//"��+",� •• • '•' a. ` ( .f ' ,•r l`r;.hl+, r5C'!�';'S n5, 1 /��/ w !h,'�11.1 t / 1, '. `•_"�CC .� � . tv ` 777, Y •"�Yl•}!p r +,7.!4"•!,^�I'4,'l',7,',, ' Sy ri Pumped 5 I X11 �V.t � .I II � •t r5ru •"'t rl J,'I`01116*+`t'4,'�I�V,Ir .55y,.�� r`�k / __• ! ,1 ;p+'tVJ'�SV r rn4Y1/,4/I(Sj 4}rI �V1'A•Y 4 Ir�'Yl✓4 i4Ill,Y.,•''• 7°, Vehicle LlGen$e Number u• �J � Ir5 '�1'i '.` h�Yy�,Y., L.'C t�'{'��'',+,JI^',i✓Y'r,1,1/ 7yF,'�jW;••.;�.,.,•fS1l1�4kJl,E:i�!,.",:IVI{ LocstJcn.wh1 contents yv�r 'dlpased; 7-44A 5 Y r} t,l t fNa i ° 111 ! L 1 iY ww••-•-, ✓J � , /J,1' 1a1 1 r r 51.i;a r�t`(,, 4,i, C ', + / ,,` . >`/.•1,•L•. ,,..�.:;+;•r";':.,,S�na�Ul®olHtsuiAf;ii,• ✓ 'l•„p.,..,... . http;!/ n�nYir.Mass,goWdep�wa ter/approv�,Is/t5forms,htm#inspect t5 docr 06!93 System Pumping Record Page i of IN us e4/OM" � 1-�l', �1 .7^� � f' �•f 7��,11�7• /y�rr.�l' GI 111 yryyN pyppyGCyy,{� ..w,_�. .� 1�1 •i'�1�,1� Ire. X11,�/�/I��I��,yll�i''��,YS',.,1 �� '^� l��w V,rr { DERhao pr (orm for u a o by local So rda of H (ao eubmlliod Vi to lhv local Board of Hoalln or oth 6x i�l�_I�i�V©a �'�W.�", • Ill rw1 -',,rWt'�sn(u;dnp oul' �.1, System I,OC�Uan,�' wllylnolabkay Aeg CWW do(tpl tea !ha ry m Y; Cih/1"Wm Sla o 11. C Coco /4. 1 Mdrosa (II dV(Q(enl (wn �QCAUOn) C tq/T t 9 -- — ----- s!� �� �°"• . mod Tolopt ono Numbor ------- ,S. '•.Y.l� ' i.VQr • � P1 a , �� M` ' tl�.• 4 IY r/'.;'•l 11 1:11�1 V �' �� ,,,^L,r a Date of Pumping` C 7 2, Quan Odle Uty Pumpec ! = --- 041)Qn4 Typ9 P�.sy3I6m1 (� ' C6sspool(s) Q,-S"Bpflc Tank Q Tlgh! TanK St ' Ochar�ld l • ' �/ ( �scriba� 1 u � Y nl ee P Ill a po n!?use Cl Y©s [ I ( f rr ti�,lr;b ��rl•,(�'��.{�'�Ig11�'� yes, Wag k Cf68n6d7 ® Ya5o` I rr�•1 � / lr: l�i���d 1pan,Q.',';✓y17� ®®�mi 1' �� tl, �,1rr � `4;II''j•1NJ� 6, .Syj P4�mp�d 6y ;il arrl�l�w,'";tr %0 , o IN VRb o ---- . , ���t;��%V I't'I��'��r• �'jJ' ��^ �� �t� �,\J'I" (//�ry1,,,,,�� �./��/�y�l r , r,/,' .+.�"'„�'1,'�(�hti�`'y' \Vi�"�'f�'�Itia� �`',�I.IY•�;�1',y•�I,I' ���j•i�}`� �(Ir•�, '/ ' ;�1�' ��oca on,vrhare co1nlenGs,wer� d1,9posad; 1 , I 1 , 1 h S I , ------------- I h�yl�w,i,,masa,9av/de •.. �a1 �Q14 --_..- pJw�l er/approvaJs/t5(ormslhlm#Inspacc Sytiam Pwnpin� f�ec=rrl� ;; `r. r4l '1 ''�y � 'SETT S COT d 4 Ji�;, p"�,r1 -!�j� ,�� y '� :J'61 /''�•}), �l,/Yi�l;{,� Y.'\ll�'I,)'I,' ., . 1 t'J.:,r1V'��(�)S/�'Itl�/,�1''!��'y),(''1r17,'n:, Ii4 rn rli,r�•7t„�VY rr ., .. 'r, ,6'U,���.r'�� , b P hay provided jtil� (orm for uuo by local Boards of Health, The System Purnpinp Rac by eubmiktvd to the local Board of Health or othor approving authority, Facility Inforrr'."atIon �n 'J YN4 h�np out 1 SXslam LocaUon Co tho tab key Address movo yoar p.�lb d0 f1Q! ✓ ��� n�,, a'd qq.0 L ;y7; � rotwarn „' ,, , �'•, own ,, •• �..,. .,. . Stab ':'�i�, �,�„4�W 4�1',�'yir',jrr;',. ,.t:�'•,1,,11}i!;w•r,1�,".�r1ir•�r''.,� 1.ia�' •. yi - ),'",',. Y3 V{y p p 'I• r'y�y� r�t1 !,),rlr�i�y�,S m NnVri.:, `FV , V j,ylyrfr J , r Y �'� �- .rr�A4dras-s (II dttferrnl rcun bcaUon) r Y-1 ,' S to t©� •�•.� p o P � mbor �f PIUm'p/nO':R�q,'Ord � �{p 01 Pu ln,Jr\ 1���'� t 1780 mp ` g p6 0 �U , llty 71 d; G auana Tight Tank ,� )a,Othar(dasc�lba�, 'Efflu 1T I 8 11 nYo97o I Y s It clean .. ,�r ' ``�,'. R"1 ,Yr)�''�'•�rd�vl r i iy)',,�5,�rill�l Jr'1 iV, �} l e \r j„i•r�' y. .4111,�✓anc on (7r•sy; �A7''m �4 , .. .•. y �. Y.,,,/ `'r �'l�n�r1'(i.VC�I�� i I,r.:��.r!i.�Irlrr Jf r, , r� :.� � ..,,.. "'""I r , � •'� a1T16 r.h w,1, ;r; �' r'+}j,Y� r , ,,I �� II v't rf,r r+l r L'oca on.wh®ra cor�lanks'Were dl�posed; {.y) trl' �r ,„,_.... -- apJhvwwmass gov/dap!�val��/a pprOVaJsitS(orm3,hlm#Inspect Sysiam Pumping Recory p{;a ray+: ,.,� •' .... KW I RY'l"',,>.f•I�ti'i'• r 0,�" )�1 y/fi:W�rL'A"iah;h'' ` •^ ip I�vl;': 'r'' '!,, •n'i , r " f ' "i Pi E1.,r�bC,''IKIr'7N�''f'�)^,,{i , 6uJ prtivlded tf�l dorm for use by local 'oards � ealth, f e Sys.•em Pum be :ubml�t®d to the local'C3oard of Health or then .PP authority, Ping Rec arc ,,, a roving Aac(I( y (Inforri'��t(on 11 (, A; — --_ �,,.Whan f ib out 1 ' System LPCakIOn; �� �. � i PAR r EII,7 only M tab key Address , W move your { _ pJriO!d I •`�•,',�.'a+r/Lr,l�"yl'ia'y SpI)o•It�i um th6'rQtumi!)'r") o�n �jw,, 1•!' i '�' '''4,; .., , FP Coda Se 2; yste 4 • �•, '\lam' ! �l�b ,.f.l fl + t I 'r ,ti » , } , , . ,. Nam®..,,,�,.�• � ;'.. , •.I. , , r...,. :.51 r,•i,'i l.' to 1. f 1 ,y, ,,�r Addra�s(IIdIKar®nt f ', ,,,,rem location) • . k, ovm , t StAta' — , qe , ,. :.,,, . ,,:,^ ,,• .,...,. 7alaP o umber — h no N , 'of P pin Pumplo r� Dat9 um q Dalo 2' Quantity Pumped; , Gallons Tank (Other(describe " ep c Tank ® Tight � , r , �flU81j(T8 e Fllty(prgm,? Yes a;�f o if s I " yes, was t cleaned ro{ r � � wr'd 4 �o.,t�Ih�J'd<�'�rl.{r;,'ay',,I; �r,4'lrf�rt )• ? .: _, rlf" ' %�t r<;";,� rr�;r,,Colidl�lv,ri'�(•�Y� 'ni �'t ' ' •>h ,x`w i htr,?'t�rl BSI:+� {.' ,I.rr,y , ..., .,. "! a'"•'':'!ir,Y.,�~r u'J^i,o,•,r,�sJ'•{{,(,lj'11a11'',,,ti.•s�, - :� romped `•t-; r,. 'alt r�:1�.,'n•'i?Fa {. y T. T Vehl 1•r.:?.'�:w rr•:,`k"'r"�.;•S��',,��,1., r�', ,$ •', �')` ;c. f, ,r 9 r.�nme Number , u,X r t;V t ,I, o, �'' ✓yry/7 ::5'!J. ° ,t: ','d.t: .%,V•pl ph '11Y`i�j�lU'y('�l� 15�/)I�(,�y,,� /� ll--{ , .. ',db�. �I•.:A��J,J.+„>, N,;,"� 1,a 1 I�JI' 1 r lI.Y.,1f,�•l•t I. �l w) i���y� .1/, 1.1,• ' ,i )!�i�`'"�•}" �' I�t)�1'.','+7�:,7{' hltl•F���j:j.0a{•�:' I a.7f.,,L'ocafl on.Whore cptents' ere' i:,:,:�;r W, r dlPposed; �` y; '�"I ; ��",. „ri'''r'rr{, � �" ,r',"t`/.t!”r,'•I�t�r.t;;li;", ,L, r., ' 5 r 0. ir.I Iv r }i I"w 1l t',�y;liri 1{ �• i d,' {,' 'V' ,t r w r a 4 a ,,r�/�yr> •;,S�nalurr®®1 H9U h44pJ'vrww,cnass,gov/d®piv✓ater/appr a s/t5forms,h data ' .. OV„� tm#lnspec( Sy$lam Pumping Record Pa ' qe i