HomeMy WebLinkAboutSeptic Pumping Slip - 168 SUMMER STREET 7/20/2016 Commonwealth lth ®f Massachusetts
City/Town Of NO ANDOVER
System Pumping Record MJN 10
a
Form 4 I() Or"'NCR'n i A04)OVER
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 168 SUMMER ST _
key to move your Address
cursor-do not NO ANDOVER Ma
use the return -
key. City/Town State Zip Code
2. System Owner:
,� BEAUDOIN, DENISE
-- ------ -----
Name
ietmn
— - - ---- - --------- -- -—
Address(if different from location)
----- ---- ------ --
City/Town State Zip Code
Telephone Number
B. Pumping ec®r
1. Date of Pumping — 2. Quantity Pumped: /D Date Gallons
3. Type of system: ❑ Cesspool(s) OSeptic 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:
�St
ewa is
Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler - Date
"Sigfta eceiving Facility ._.�..�..�.. �
y .., .. ._... ...M. ate
t5form4.doc•03/06 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
North Andover, Massachusetts
Swstern Pun!ping Record
System Owner & Address:
Suellen Torregosa
168 Summer Street
North Andover, MA 01845
Location of system: Front, right
Date of Pumping: March 27, 2014
Type of system: Septic Tank
Gallons Pumped: 1500 gallons
System pumped by:
Service Pumping& Drain Co.,Inc.
S Hallberg Park
North Reacting, Ma
License #: BHP 2014 0120, 0121, 0122, 0115, 0116, 0117, 0119
Contents transferred to: Greater Lawrence Sanitary District
Date: March 27, 2014 Pumping Technician: TD
This is PROPRIETARY and CONFIDENTIAL information that may
be used only by the Board of Health for regulatory purposes
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
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 CIVIR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
pp
on the computer,
use only the tab /
key to move your Address
cursor-do not North ANDOVER Ma
use the return City/Town State Zip Code
key.
2. System Owner:
\f '
Name
tewn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping OUC 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. 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 m� K8 Massachusetts
��[]�]�1(�[]VV����/u / `�/ /v/��������(�/ /[]��`°��~�
C'+ //T ow[ of North Andover �
/
System ump.ng Record
�
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. Bafmna using this form, check with your |
|000| Board of Health to determine the form they use. The System Pumping Record must be submitted to �
the |ooe| Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CyWR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use 168 Summer o,
only the tab key Address
m move your North Andover Ma 01845
cursor'do not
City/Town G�� Zip Code
uoe\heogum
hey.
2. System Owner:
Beaudoin
Name
Address(if different from location)
CityfTown State Zip Code
Telephone Number
B. Pumping Record
5/23/11 15OO
1 Date of Pumping 2 Quantity Pumped:� Date � ' � Gallons
3. Type of system: F-1 Cesspool(s) Septic Tank 0 Tight Tank F-1 Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? El Yes El No If yes, was it cleaned? E] Yes F-1 No
5. Condition ofSystem:
Good Condition
8. System Pumped By:
Bruce Merrill
Name Vehicle License Number
Stew Service
Company
7. Location where contents were disposed:
tewart's Pre-treqq�Ment Plant, 20 So. M iLl Bradford, Ma 0 183
gnature of er Date,,_
Signature of ceiving Facility Date
�
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