HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 9/14/2016 Commonwealth O� Ma,ssaejhuse s
Cityfown o� P b Andover
.o
Vorm 4
DEP has provided this form for use by local Boards of Heal h, Other forms may be usec
inform ation must be substantially the same as that provided here. Before using this fora
local Board of Health to determine the form they use. The System Pumping Record mu;
the focal Board of Health or other approving authority within: 14 days from the ournping c
accordance with 310 CMR 15.351,
A- Facility Informat9ofia
inpartant'When .
511,n9 out;ons I' Location:
an the computer,
use only the tab 3 S ,
trey to move your Address 4 -
cursor-do not
use the re u r, North Andover
key- C'rlyrown _ ..._.._..
OL—N a�iai2 ? Zip.p
C
2. �.
System Own
Name
15 7
�U ...._......
odr m d'r`erenG from t
Cityrown
State _.. zip Cc
RECEIVED �. PuraPlng Record telephone Number -..,_._.._.._.._.__._
T 14 2(x16
1. Date of Pumping ° �....
7OVV8jN�OI'CHAND VER Date 2, Quantity Pumped, �
- .i &V�.,Vl_i 1,1P_h'tG��ki iY llV Gallon:
3. Type art system: ❑ Cesspool(s) ❑ Septic Tank Tight Tank ❑ C
❑ Other(describe): _ _ ...•..., .:-..._...:_..._.. _ _ _....... .,
4. E-iuent Tee Filter present? ❑ Yes ' No
If yes, was it ci'earrvd? ❑ Yes
S. Condition of System;
6. system Pumped By:
-VE..
Name ......
..
Stewart's Septic Service Vehicle License\umber
Company
7. Location where. n`ents w re disp ed: �
Stewart's Pr = kment I S ill Bradford, Ma 01835
,
Signature a`Haule ---..___.....
Si na— tureos-- -.--_—° _
9 Receivin F 1 _ ..
9 act ry .. �.�..
Da'te
t5`on4.doc-03l0fi
❑OMMenwealth Of Massachusetts
' of Nbi th Andover
System- Pumping Record
�-orm 4
DEP has provided this worm for use by local Boards of Heal h. Other forms may be usec
info-mation must be substantially the same as that provided here. Before using this forr:
local Board of Health to determine the form they use, The System Pumping Record r�u:
the local Board of Health or other approving authority within 14 days from tine pumping c
accordance with 310 CMR 15.351.
A- Facility Wor atj(Dn
impo,—cant:-when .
MIMSot form S 1. System Location:
on'he computer.
__ .
use only the tab �d
` �4y
key to moue our
cursor-do not
use the return North Andover
key. G' ! awn at '—,.,....-_....,...-_.......,_.. _
e.
Zip C
2, System Owner:
I �
Name
Address(rc d'iff'erent from location),_ ,,,,• „"'". °°•,._ .._-.
C /i own •--•--,_. .
State Zia Cc
—
` Telephone Number ...........
. PUMPJng Rec ord
ng FM1
Date o Pumping
EIVE Date.._.._,_. 2. Quantity Pumped; c"
?016 3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ -ight T 2nk
1 MM l NOF'P 4.AP4[)OVER ❑ Other(describe): .. ...,._
HL/I H]i U
a. Ef fluent Tee Filter present? ❑ Yes Na !;yes, was ii clean d?
5, Condition of System.:
6. -a ystem Pia ed By:
Vehicle License Number — — —
Stewari's Setatic Service
Company .-
7• Location where contents were disposed;
Stewar~`,-- Pre-treatmen' ant, 20 So, Milf Bradford, Ma 01835
Signature o`Hzi
r,
Date
Signature of Receiving
g acdty Da'e. __-._„. ....,•...,.._,.,
t5torm4.doc•03/06 '
❑omrnonwea•th of Ma.ssachusetts
C I ty/T -own of Nbit Lh Andover
System PumOng Record
orm 4
DEP haslprovided this form for use by local Boards of Health. Other forms may be used. but
10
information must be substantially the same as that provided here. Before using this form, cN
local Board of Health to determine the form they use. The System Pumping Record must be
the local Board of Health or other approving authority within 14 days from the pumping date i
accordance with 310 CMR 15,351.
A- Facility Information
Importan':When
1-511ing out forms 1 System Location:
on'the computer,
use only'be tab
key to move your Addy
kddress ------
cursor-do not
use the return North Andover
key.
6511�i ate Zip Code
Z System Owner:
Name ......
Address(if d i4iferen,,from location)
Zip Code
Telephone Number
Pumping Record
1. Date of Pumping
0 Date 2. Quantity Pumped:
Mons
3. Type of system: ❑
Cesspool(s)
CClW�,j OF, ANDOVUR, El Septic Tank T ight Tank 17 Grea:
ME'4T
[iEALC� am /Other(describe): _LQ
4. Effluent Tee Filter present? ❑ Yes ❑ No If Yes, was it cfeaned? ❑ Yes
5. Condition of System:
6. System Pumped By:
Szewart's Septic Service Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's, Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
-a'e..--
D
te
,5"o-4.doc•03/06
Svs-Lem Purnninn P.—A.
Commonwealth Of Ma,ssachusetts
North Andover
City/own own of F
System- Pumping Record
............ Tx Form 4
DEP haslprovided this form far use by local Boards of Health. Other forms may be used, but
information must be substantially the same as-that provided here. Before Using this form, chE
local Board of Health to de-termine the form they use. The System Pumping Record must be
the local Board of Health or other approving authority within 14 days from the pumping date i
accordance with 310 CMR 15.351,
A- Facility Wormation
-
Important::When
I'll"T19 out forms 1 System Location:
on the compmer,
use only'the tab S
key to move your Address
cursor-do not
use the return North Andover
'
key. ate ip Code
2. System Owner:
----------------------------
Name -------
Address(if different from location)
--—------------
State Zip Code
Telephone Number
Pumping Record
RECEIVED I. Date of Pumping
Date 2. Quantity Pumped,
Gallons
t
3. Type of system:
f D Cesspooi(s) ❑ Septic Tank ❑ T ight Tank L_<Gl e a,,
❑ Other(describe)-, -- ._ _�_l.' . " W_.f P
4. Effluent Tee Filter present? Yes El No If"yes, was it cleaned? ❑ Yes
5. Condition -f System:
...........
6. System Pumped By:
Name
Stewart's Septic Service Vehicle License Number
7• Location where contents were disposed:
Stewart's Pr reatment Plant, 20 So. Mill Bradford, Ma 01835
Sig u5'of
r
Sign ure of ib uler
_S,g atue
Da'te
k5fo.-M4.doc-03/06
SVSZem Ptirnninn P.,�
Commonwealth of Massachusetts
CYf_
own of NbrIth Andover
.Systems Pumping Record
Form.'4
DEP hasiprovided this iorm for use by local Boards of iHeal',,-h, Other forms may be used, but
information must be substantially the same as that provided here. Before using this form, cN
local Board of Health to determine the form -hey use. The System Pumping Record must be
the local Board of Health or other approving authority within 14 days from the pumping date i
accordance with 310 CMR 15.351.
A- Facility Information
Importan':When
'211ing out;orris 1- System Location:
on the compL,,,er,
use only the'tab
1,o moue I
key UN-,
ve your Address
cursor-do not
use the return Norh Andover
key, //Town ___-
ate Zip Code
2. System Owner:
Name
ieur
Address(if different rom_fo_�tion_)
city/Townes— -
......
State Zip Code
- Tefaphone Number
CEIVED Pumping Record
I Date of Pumping
Date 2. Quantity Pumped.
Gallons
I.OWN OF N01`7H ANDOVER 3. Type Of system: Cesspool(s) Septic Tank D-1-ight Tank ❑ Grea,,
K`A�Ifl L)EFARIMENr
❑ Other (describe):
4. Effluent Tee Filter present? ❑ yes yes, was it cleaned?
❑ yes Ej
5. Condition of System.
(17
6. _ystem mped,6y:
Nam
Stewar-cs Septic Service Vehicle License Number
-company
7. Location where contents were disposed:
-Stewart's R(Ottreatment Plant,
20 So. Mill Bradford, Ma 01835
Sig azure of Hauie—r
19n8ture� Receiving f _F�acij'rEy_ -a I te . ..........
,5f0rM4.doc-03/06
Svstern Pumninn P.—A.