HomeMy WebLinkAboutSeptic Pumping Slip - 36 SHANNON LANE 7/13/2016 Commonwealth of Massachusetts
L�W-ALJHDE p City/Town of North Andover
System Pumping
f
Form TOWN t ANDOVER
t. RTI NT DEP has provided this form for use by local Boards of Health. Other for ;
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
the tab
filling out forms 1. System Location.
on the computer,
use only - -
key to move your Address
cursor-do not North Andover Ma
use the return -
key. City/Town State Zip Code
2. System Owners
Name
return
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping czar � .
1. Date of Pumping - 2. Quantity Pumped:
d Gallons
3. Type of system: ❑ Cesspool(s) 0 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: ,z, �
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
Sig is are of Hauler Date
�i"gna ur of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record^Page 1 of 1
a
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER S
System in Record
Form 4
HAY
DEP has provided this form for use by local Boards of Health. T7System ng Record must
be s ubmitted to the local Board of Health or other t�t,"ALT D
A. Facility Information
Important:
forms on the .
Men filling out 1, System Location: ( µ _ , ~~
computer,use
only the tab key Add res -
to move your r
cursor-do not ) __. a
use the return Cltyrr n State Zip Code
key. 2. System Owner:
Name ---
" Address(If different from location) —
City[Town State Zip Code
Telephone Number —
B. Pumping Record
� f
1. pate of Pumping Date 2. Quantity Pumped: ` 6 —
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:
6. S stem Pump ed By:
pj e ] Vehicle License Number
f+ I_ V`w
Company
disposed:
7. Location where contents were
p
S H,atPrb,of Hauler pa ,
http://www.mass,gov/depAvater/approvals/t5forms.htm#inspect
t5form4.doc 06/03 System Pumping Record-Page 1 of 1
Y ' ASSACHUSETT
A
s
hh
SVF
0,q
: p y.
CEP,.hae rdvlded tht forrn1for use b Jlc ! Boards of He The System Pumping Record must
be�ubmt4' d to the local Board of Health or other approying authority,
; rr „
A, Facllify Inforni`afl®n
trt;portant
-,�yvhen filUng vut 1 . System Locatlon
forms,on�, ,
r
i..:.'computer,use ,✓
only the tab key Address
to move your:; e �
.ourw.do pot Mal
the retum'> City/Town
„ Zip Code
System owner, 1
1
' Address(If different from location)
City/Town State Zi C e
Telephone Number
Pur
t 1' '�l II,ai � !•r fi ,19n)l�t'�,Y'r{i,"°�14 � ..
11 , " a Dato i
of Pum� n
p q date 2. Quantity Pumped, Gallons
TYp®4f syst®m Cesspo Ej Septic Tank ® Tight Tank
Other(describe);
Effluent Tee Filter present?. Yes No' If yes was it cleaned? ® Yes
I No
�afrditlan pf Systm;'"
1 ti � r.'' r yl`J I,r ill 9lr('k.. ',v r, 1 dl,,•l. nk', 11.`
Pumped Sy;
• I 1 I, '{,'•! Y. 1 fry .,
� I
y ,
Ve_hhicle Ucan$e Number
r� rk
yr 1 at GA1Tl_p y,Y�J�AA{�1P1, 4y�Y Ji1I�U� t� tip.
�! ��y' I✓ V
4,a4',QTw� �' �1�1�•1�t:.+79(Y�"y,.,A� � ' .,
7a Lvcan wharq contents yvers�disposed;
(4 YI
^r r t'#.f� t a'r(•.I +r1 „I/ia.l ,+, 1 , 1! ,.
t Y. � a Y^c',Y ✓ , Date
au rRI l•
h ppeQVa,1s/t5forms,htm#Inspect
t5f do,.-Cl6/09 System Pumping Record a Page 1 of 1
Commonwealth of Massachusetts
City/Town of I ;E
System Pumping Record
..° Frarrn 4
DEP has provided this form for use by local Boards of Health. The`S. s ��'ui m yin Re�cerd°must
y p g
be submitted to the local Board of Health or other approving authority, .
A. Facility Information - - -
Important:
When filling out 1. Sys m Locatio
forms on the
m
r
computer,use
.,_ \ —
only the tab key Address
to move your °r � �` �
cursor-do not -- - --—
use the return City/Town Zip Code
key.
2. System Owner:
� « --
Name ---- ----
- —
""`" Address(if different from-location) --- ---- --- ----
Cit /Town
- -- -.
y Stag de
---
"o
Telephone Number — — —
13. Pumping ec r --
"
In c D
1. Date of Pumping ' . 2
Pate --
Quantity Pumped: Gallons
3. Type of system:yP Y ❑ Cesspool(s) [peptic Tank El Tight Tank
❑ Other(describe): -- -------— ----- — ------- -
w�'
4: Effluent Tee Filter present? ❑ Yes .-10 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste
6. S Put�ped By
y .. _ .. �
Name — — - — — Vehicle License Nu -- - ----- -----
�= � tuber
Company ---
7. Locat' 'n"where contents were 'sposed:
Sig lure f H uler pate -- --
h,ttp://www.mass.gov/dep/waterlapproval8/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
TOWN JC T � ,r,Or
SYSTEM J I
IRATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATI ON
(example: left front of house)
IRATE OF PUMPING: ,—/S QUANTITY PUMPEID GALLONS
CESSPOOL: NO '�YESn SEPTIC TANK: NO YES
NATURE, OF SERVICE: ROUTINE EMEL2GENCY
OBSERVATIONS:
GOOD CONDITION FULL,TO COVED
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLILDS FLOODED
SOLIIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: Q-)
COMMENTS:
CONTENTS TRANSFERRED TO: "