HomeMy WebLinkAboutSeptic Pumping Slip - 485 FOREST STREET 6/28/2016 Commonwealth Massachusetts
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/�'f y� � North Andover
City/Town����[l ��/ x���/ ^/ / ���lwover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be usad, but the |
|
information must be substantially the same as that provided here. Before using this check your
� . �
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local ""a.° ". Health or other app","'x a""='`y within^ 14 ~~'~from the /
accordance with 310 CMR 15.351. 1`,4!,ECE1VED
Important: A. Facility Information 0 11
When filling out 1. System Location,:
forms onthe
u
t ......——-------
ompun,r, use A J(111A%71-�- ,
only the tab key Address '
m move your No.Andover Ma 01845
ouspr'd»not Ci��own State Zip Coda
use the ogm
u
hey. \
� 2. System Owner: |
Name
�
Address(if different from location)
Cdy[Tuwn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2� Quantity Pumped: Gallons —
Date 3. Type ofsystem: El Cesspool(s) ""Septic Tank Fl Tight Tank || Grease Trap
Fl Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? El Yes El No
5, fS �
> t
O.
Pu Go,B
N�me Vehicle License Number
Ghawarfe Septic Semimy
Company
7. Location where contents were disposed:
c+e art's Pre- reatment Plant, 20 So. Mill Bradford, Ma 01835
�
i n Date
Signature
t5fom4dmr03/0 System Pumping Record ^Page 1 of
Commonwealth Of Massachusetts � � I VE . .__
City/Town of
System Pumping Record 2009
Form 4
DEP has provided this form for use by local Boards of Health. Other forms +set I o
�i�s
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.
A. Facility Information
Important: , ... „
When filling out 1. System Location: Left fron ,�IWrear eft sid of hs eight front, right rear, right side of house.
farms on the
computer, use
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
Name - -
! -_ Address(if different from location)
Cityrrown State y ZID Code
Y'
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
1 Type of system: r] Cesspool(s) _ eptic Tank Tight Tank
Other(describe): -
4. Effluent Tee Filter present? Yes �� If yes, was it cleaned? Yes No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lor�S. here contents were disposed:
Q. Lowell Waste Water
fligna Pureof u r Date
t5form4.doc^06/03 System Pumping Record^Page 1 of 1
Commonwealth of Massachusetts
EI
T RECVED
T:
T;�
City/Town of NORH E
ANDOVE- SACHUETTS
System Pumping Record
Form 4
u,p "J"OWN OF NoRt,�rH AWOVER
DEP has provided this form for use by local Boards of Health. The Systim'"L
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location, w V-)
forms on the
computer,use
only the tab key Address
to move your CA
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
'Y'('
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record i
1. Date of Pumping ntity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) P/Septic Tank ❑ Tight Tank
❑ Other(describe):
ro
4. Effluent Tee Filter present? ❑ Yes El No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pu Ma d By:
-n
Na a 1 Vehicle License Number
Company
7. Location where contents were dispos
V
0- AvAl
S' ture of Hauler Date
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Commonwealth of Massachusetts
City/Town of )U7
System Pumping Record
. ,
ugFora 4 Oi i ii rDOvE:i
DEP has p i y
local provided c nghis c
Information mu be substantially he same as that h re. Before usig thiform, heck wu
ith 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.
. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use ;_..... a„
only the tab key Address � ~°� „---�. °-
y t . .. " ,. °,.._
to move our �. <
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
leb
Name
gun, 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) IT Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑—°N6'__ If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: w.
6. System P mped By:
Name - Vehicle License Number
r _
Company
7. Location here conten s we t osed:
AD
._ ,. �7
Signatur 0, 116ul Date
t5form4.doc•06/03 System Pumping Record o Page 1 of 1
CorTirnonwealth of Massachtisett
MC
, �C
.:r
f�
�r r n Record
P Form N V 1 20
. provided Boards � n �
be
submitted t the local Board of Health or other approving at� �mmr
A. Facility Information
Important:
wherr filling out 1. Systern Location:
forms can the to//
computer, use
only the tat)key Address �w
to rnove your
cursor-do
o nr _
use the return City/'rown State Zip forte
key.
r
2. y�strrt Owner:
Name
,�rtctress — —
.._..__,�. �' (if clrtfororat from Icacation)
City/°rown :state Zip Code
relephone Numhe l-
PUMPirig -Record
1, Date of PUmping rt� 2. QUalltity f�aurnped: �-
r�alicync,
Type of systern: �� C esspool(s)
rs
eptic Tank �.w._a Tight Tank
r Other (describe): -
4. Effluent Tee Filter present? � Yes rW. No If yep;, was it c.l ned? �_.� Yes [ � No. Condition of System:
6, Sy, earn Purrlped Nay:
r� °Crt ,W (6 f _t 11/'y
w.m
Name Vehicle License Number
� {
Company
,f
7. Location where contents were disposed:
r
f =�
SOpKatcire of 1 traulra Date
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SYSTEM OlWNER && ADDRESS
�..._. SYS"T"EM LO(:"A'T`TC;)N
DATE OF PUMPIN(l
QUANTITY PI PF,D _ _._..
t.'0SPCX)L.: NC)-.. .. YL;S Y
... _ `iOptirr I'curk; NC)_ YLSI"
NA rote: OF SERvICE: ROU IN
08SHR V A rIONS:
GC)G1>C?CONDITION FUL L TO COVED
HEAVY GREASE BAFFLES IN PI�AC;.L.
ROOTS LEACMU1.D RUNBACK
EXCESSIVE SOLIDS FLOOL7F
SOLID CAR.RYOVER...........Q'I'HF:R EXP1_AIN
synrvrrr F>rarnpeci by
C'UMMENT,)
CU I L I S UKANSF'L:R RE,C) I t
ComnNamealth of Mossactwuselss,
w Massachusetts
yfierri Owner � System I. atiarn
Cesspool. F mr 7y"Oust"
Septic tor k. Ida ye,. u
a����'
bate crpa Punrpdwmg.� C�wrcawrtlty Pumped: � C�G,�"`�.� aIparres
System Pumped y: Wind River 1:"rrvir^crrrrrr natal, 116' P rwnit �.
Contents transfenvd trr:
Contents bisposed mat;
We: S :r .� Pmrrraper^ 6mturr:.
Condition of SystenVOther Crammnents ��
bep Approved Form - 12/07/95
TO" OF NORTH ANDOVER
SYSTEM PUMPING RE, COIZ.D
1 �'1'Lhi OWNER & ADDRESS SYSr'EM LC7CA f"ION ___.---
(ex rnPie; lelt front of houNe)
/)K""c
U �"1 E OF PUMAINC; � QUANTI'T"Y PUMPED /,��- �
C,-� L1-0
!:ySi'UUL: NO YES SEPTIC TANK. NO YES
� ATURE OF SERVICE: ROUTINE EMERCENCy �
O (:R V,:DTI0Ns:
COOD CONDITION FULL TO COVED °'-,
HFAVY CREASE BAFFLES IN 1'L,ACL,; _
ROOTS LEACHFIELD RUNBACK
CXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER J, HFR (EXPLAIN)
, 1 'I EM PUMPED BY:
U I I:'N'rS T] ANSFC(7RLD TO:
TOWN OF NORTH ANDOVE R
SYSTEM PUMPING RECORD
DATE: S" el)l
SYSTEM OWNER ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: ° t QUANTITY PUMPED_ GALLONS
w�
CESSPOOL,: NO Y,1+ ; .,� ASEPTIC 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)
COMMENTS: ....• .- ,