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Home My WebLink AboutSeptic Pumping Slip - 145 FARNUM STREET 7/20/2016 Commonweal th Of i1/I ,�;sachuS ttS ----- ` City/Town of North Andover PumpMg 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 CMR 15.351. o�,. V ED A. Facility Information Important:When �,Cil filling out forms 1. System Location: -,� on the computer, \ &-li �I i:�,4 r'lk,ICS-.GJh use only the tab -- key to move your Address cursor-do not North Andover usethe return -------...._....._.._._. . ........ .......... _.__..., -– -. ........ -----.— key. City/Town State Zip Code 2. System Owner: Name Address(if different from location) Cityfrown State Zip Code B. Pumping Record 1. Date of Pumping - - - --- 2. Quantity Pumped: - / — ------ - Date Gallons 3. Type of system: ❑ Cesspool(s) mrseptic 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: Vehicle License Number Stewart's S ice Com ny _ . ..._.... -. 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.docr 03/06 System Pumping Record•Page 1 of 1 Commonwealth of I assach a tts' City[Town of No Andover- System Farm 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 filling out forms 1. System Location: on the computer, w use only the tab ❑ r)1(JYY""l 1 key to move your Address cursor-do not No Andover Ma _ use the return City/Town State Zip Code key. 2. System Owner: Name reran Address(if different from location) City/Town State Zip Code Telephone 1,1umher B. Pumping Record � le) 1 1�5co 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Z 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. S tem Pumped B 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 ure of Hauler Date of Re r vivg , l Date t5form4.doc>03/06 System Pumping Record<Page 1 of 1 Commonwealth of Massachusetts r City/Town of No Andover } System Pumping con 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 filling out forms 1. System Location: on the computer, // , .. use only the tab T, ,� ffiIrn((Yy) � -- ----- -- key to move your Address cursor-do not No Andover Ma use the return Cityfrown State Zip Code key. 2. System Owner: r� i Name rehnn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping ecor M. 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Ix 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 moomwm;wmrwwwmiwmwuumuawwanvmvasmrvammuw,mnwn,mowammu womiowumnw¢w Commonwealth of Massachusetts R (""0' I l'o, )) City/Town n v r R)N °I (1 ,701""i Pumping SYStem i :AN i rig P�wt::af IM I N rOVEFt lug .� rid Y�r Form . DEP has provided this form for use by local Boards of Health. Other farms 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, °w. . use only the tab key to wave your Address cursor-do not No Andover use the return Ma key. Cityrrown Mate Zip Cade 2. System Owner: Q , Plame Address(if different from location) City/Town State Zip Code Telephan�Number �� 1. Cate of Pumping Date 2. Quantity Pumped, Gallons 3. Type of system: Cesspools) ErSeptic Tank El Tight`rank El Grease Trap El Other(describe): 4. Effluent Tee Filter present? Ej Yes Ej No if yes, was it cleaned? El Yes El No 5. Condition of System: 6. System Pumped By: Name Vehicle License Plumber Stewart"s Septic Service Company 7. Location where contents were disposed: SteWbrrs Pretreatment Plant, 20 So. Mill Bradford Ma 01535 Rbu)er Signature of Receiving Facility Cate t5form4.doc^03/06 System Pumping Record^Rage 1 of 1 Commonwealth of Massachusetts City/Town of No andover o System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may 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 4 Important:When filling out forms 1. System Location: on the computer, use only the tab i'A key to move your Address cursor-do not Nn Andover _ ''J,a _ use lire return key. City/Town State Zip Code 2. System Owner: f t r� �\ O _ Name ream Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping r� 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 ❑ No 5. Cundidon 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 Sign e, f auler Date S. n ur of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 INfIrtfM101001110 R9 Commonwealth of Massachusetts F City/Town of No. Andover jU1" "I ' @,011 System Pumping Record TOWN OF NORTIi ANDOVER Farm 4 DEAL,tlt DEPPATMENT 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 1. System Location: _ w forms on the /. w computer, use __ - - — "- only the tab key Address to move your No.Andover Ma 01845 cursor-do not Ci -------- - at - -- use the return City/Town State Zip Code key. 2. System Owner: ' r� C ' Name �. -- -- _. ----- �� Address(if different from location) City/Town State Zip Code ----- --------- — Telephone Number B. Pumping Record 1. Date of Pumping i. ��—� 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 ❑ No 5. Condition of System: 6. System Pumped B AC Name j 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 Recei ing Facility Date t5form4.doc•03/06 System Pumping Record-Page 1 of 1 h4f prvvldad )hl� loan r�r � 1O -v ! Col aoeJcl �a• � �� o +'.v.ml ;pollo lho lord 6crrc C'J �o011n or culo� I a+o,�l, �,�,�". , , r I I A' Facility In(arm�llon 'v C'I- NOR 1 i P,� )VE A w.�EP,�T II:�. I_T��1.11 I �� Af VM r1(m ;' � l,Jf '��''IY'�Y�'�14 /' ,'i�`'1�.�,1i(aa+ , � '+� •.�'. I � 51111 --.... (I/dVfuIMI rain bwVon) ",-P Onl h rn01 Pumpl��'R��ord o8 o of P �mgln9 n, a f,�,• SOpLc Ton, ' '"�'.)-Otho�r (doscrtba� ISM, ray. �muon)l Too Fllip('pjq,�enr? r' Yos C3 n'o . 1!Itll p„, If �' -�'a:6,'�� ' 1, ,(��Y,r v)•, �..�'' �IV'I� r,ynlr+l,y•h�y'.f.ti;�`,{�YI(a' �� "� > f Lx) �3T '��".(: �i,;` 41., .�,yY/p11�411I��fl✓C,"-�,�,d,l' �'111111'1,,4�'�/I��J' :,; ,1;,,• ;J�,,r�l ,.��rhar�5��onlon�+;y�ravi,e d�9posoo: Stan o vlhlvw �,y,s�,,.•,;,,,, , r:w�.,, o rid o p�;%'s j o r g 'llipp oYe/a worm3.n.fn,vrn9p�cl t � u DC � , o,"il,,(I 'y/�,A+ /�I{''1. �l�,k+l��:y✓�{{�'``Y�1\i' tr' � „ 1)EP,ha4' proVldud jhla form for uuo by local Board* of Hoallh, Thu System Purnpl;, be submlljad to the local Board of Hual(h or other approvinp aulhodry, Ai Fa�llity Inforri'�`atic�n TY�a� II a ovl i. Sys(am LouUon fauna an Via,, .. 1 only lha tab kay Aoorvs, ' ZJP C X Nnary �,`I �, �.��G lyr'i�rf).,rf.,;Y'yla lr)i},li�14, ,i,un Illir•0, r,,,....... �/ p�•�r,r�y IYP dlfill i ) ram loc kn C kqR own --- ., f � Pum J;Rog rd , II . r R Dals of Pumping 2 ` ' �uan ftty Pumped; �, ,• Callon, YyD� P�.�yslem; Cesspools) Ey"5"opllc 'Tank � Tight Tanx r, a Effluenl ryailr� „J nr? C] Yes No If cleaned?Y05, II eane �. was d? Yes o„°" °�I dJ by Condl�lon .1,v-+ ryytnY 1/'/" ,f�J J '., i' •I�,,I f' r �� .._...� Pmpad By .. (,1 '� •� �c 1 41,�� •'��. y✓9�IC�b/I,��G'�ell�}1 NUlf1�9( f, UU1 J • ' i'il , � s! ViU'f!i , /I��i,v,y�i�' '1 1 I� fl{�,,1 ,IJ,1, �p�Iti 1+ � '1rIlOGBq C1� 17` on when conlenls'ware dlpos©d; o o -- 0 hJhJrww�rn a ,8ov/dep!haler/approvaJa/l5(orms,hlminspecl '.v`�^nI.CG. GC/Q� 5ytiem Pumpinp�ReG;,ry F1, - Commonwealth of Massachusetts 1 z City/Town of _ T �p 9 System Pumping Record Form 4 { 1'I Pf flfi f [CEP has provided this form for use by local Boards of Health. The ystet Pumping Ftecord r(nust 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 only the tab key Address to mare your cursor-do not - --� _��'_ �. �v _ use the return City/Town -- State -- - Zip Code ----- ke y. 2. System Owner: Name --------------------------- - --- ----— ----—-- — -- — —-- Address(if different-- from-- cat loion) -- --- _ City/Town - ---- -- .— State Zip Code `' . . Telephone Number B. Pumping Record w" 1. Date of Pumping date 2. Quantity Pumped: dons - ^— 3. Type of system: ❑ Cesspool(s) r Septic Tank ❑ Tight Tank " ❑ Other(describe): -- 4. Effluent Tee Filter present? ❑ Yes( -No If es was it cleaned? Y El Yes ❑ No 5. Condition of System: ------------ 6. System Pumped By: ,Nam Vehicle License Number -- -- Company — , 7. Location where contents were disposed: �k '4'e d .w.., " , 4, oe SigntuFe Date --- - - — http://www.mass.gov/dep/w r/approvals/t5forms.htm#inspect t5form4.doc-06/03 System Pumping Record•Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD ,.1 �'I'EM OWNER & ADDRESS SYSTEM LOCATION ( 71 (e: left front of house) ( U,\TE OF PUMPINC; "` (QUANTITY PUMPED_J� O 0 A L,L � SPO0L: NO YES SEPTIC TANK: NO YES � ATURE OF SERVICE: ROUTINE EMERCENCY GOOD CONDITION, ''~�", PULLTO COVEk HFAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER �Q�HRR (EXPLAIN) T �Y.�TLM PUM ('CD BY: ° r ( U M M FLATS; fMd UN" TIZANSI'EIZItED TO: