HomeMy WebLinkAboutSeptic Pumping Slip - 202 FOSTER STREET 6/7/2014 w op• w �✓,4gY4 �8
. System
Fora 4
DEP hes provided this form for use by local 89ards of stealth,,Other forms may be used, but the
information must be substantially the some tap that provided here. Uefare using this forth, ctleck witi1 your
local Board of Health to determine the form they use.The Sjjj#M Pumping Record must be Subrnitt d tc;
the local Board of Health or other approving authority within 14"days from the pumping date in
accordance With 310 CMR 15,351•
E
A. Facility Information
lrrrp rrt n U 01
filling out I. System LocaGan:
on the pater, -. ,. _ rc)VVANDOVER
use only tab , ` >� t.l�j lea:-� �T n►: T
key to move your
cursor-do not
use the return ,6L A t'l �f� ve
key , City/Town Stew Zip Code -_ w,. ......
43 . System Owner
Address(if different froon location)
CirylTovan State'
3/6
Telephone Number
B. Pumping RO r
1, Mate of Pumpirtg Date 2. Quantity Pumped: ��►�)�� ._..�_.w...._w
Gallons
3. Type of system: Cesspool(s) Septic Tank Tight Tank EJ Grease Trap
[I Other(describe):
d. Effluent Tee Filter present? i) Yes ® No if yes,utas it cleaned? 11 yes Ej No
5. Condition of System,
5. System Pum By:
�a Veh• License Ntanber
(2 K
Company
7, Location where contents were disposed:
S' natures-
e o� lar
Signature of Rem*g Facility
t5formA.doC•03106 System pumping Record•page 1 0►;
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p i t r.f s .._-._..._._.__
State fip CoCKI
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t if sent ,.ro e .tocatioll off'pump)
Stat, 7i :ocl,
Rumped_ db
PUMAS
Cornparty: R.00TER-JAN 46 Por sand SiTe t Lawre;ice, MA i; 343
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` C 7tlit• -where� i C GC7t1t�'nt' lhy
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j�j�" I 4
Commonwealth of Massachusetts
TOWN OF NORTH ANDOVER
-1 DEPAR,rMEN'r
City/Town of �\J()
System Pumping Record
Facility Information:
System Location:
Address
City/Town State Zip Code
System Owner,
Name:
Adress (if different from location of pump)
City/Town State Zip Code
L)
Telephone Number
Pumping Record
Date of Pumping Quantity Pumped,_.___ gallons
Type of System /K Septic TankGreaseTrap Other _(what)
System Pumped by:,,
Company: ROOTER-MAN 12 East Dracut Rd., Methuen, MA 01844
Location where conte is were disposed:
Signature of Hauler.- Date
.-
711
Commonwealth of Massachusett
City/Town of �j d me
System Pumping Record E C E I V E D
JLIL 1 4 2008
Facility Information: TC)WN C)F` kA,NDOVET?�
System Location:
Address 0 4-tAdoje K aYl
City/Town State Zip Code
System Owner:
-C
Name:
Address (if different from location)
City/Town State Zip Code
Telephone Number
Pumping Record
Date of Pumping quantity Pumpedgalloos
Type of System: Septic Tank Grease Trap Other
System Pumped by:
Company: Rooter-Man 12 East Dracut Road, Methuen, MA 01844
Location where contents were disposed:
Signature of Hauler Date:
Commonwealth of Mas ach sefi s
U :i. 0
Cit /Town of f
System Put i�
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 Of other approving authority.
A. Facility Information
lrrrporLant:
form to ttra
cornpuker,use _//___a �.__.
l &
y y Location:
,.
�e,n filling quk sem
only the Lab key Addiess
to move,your
cursor-do not
Cit (Town
u5u th<eeturn y State zip Code _
key. ,
2. System Ot-e
, •
lid
qw Address(If dikferefrk from location)
— 7
Stake � ��LL�ua
Telephone Numbef
S. Pumping Record
1. Crate of Pumping
Qdk4; 2. Quantity Pumped. Gaup
3. Type of system; ❑ Cesspool(s) Septic Tank
❑ Tight Tank
❑ Other(describe):
A, Effluent Tee Filter present? ❑ Yes
. _ ❑ IVa If yds, wad it cleaned? ❑ Yes El No
5. Condition of System:
s. systert,Pat ped
l I Vehicle Liven Number
in
7. Location where contents were disposed:
$
ignature of Hauler — __s
Dake _.—._-_._.
t5form4_doc*0&/o3
System Pumping Record Payee 1 of t
TOWN OF NORTH ANDOVER
SYSTEM. PTJMPIN "° RECORD
RECEIVE
�f
DATE: L 13 2004
TQWWN OF NC�F T i DOVER
_ TN DEPART 'ENT
SYS EM OWNER ADDRESS ; SYSTEM LOCATION � -
(example: left front of house)
DATE OF PUMPING: QUANTI'T'Y PUMPED GALLONS
CESSPOOL: NO y YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS: FULL TO COVER
GOOD CONDITION
HEAVY GREASE _.__ BAFFLES IN PLACE
FOOTS LEACt"IFIELD RUNBACK
EXCESSIVE SOLIDSFLOODED
SOLIDS CARRYOVER _ OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS-
0
CONTENTS TRANSFERRED TO: ?r
i
TOWN OF NORTH ANDOVER
z
SYSTEM PUMP'IN C O
DATE: � ....
SYSTEM 'WNERESS SYSTEM LOCATION
(example: left front of house)
IDA,TE T+ PU PTNCx m
UA NTITY PU PE L--OL),
. ), GALLONS °au
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE �°°� EMERGENCY
OBSERVATIONS: ,.,...
GOOD CONDITION " FULL TO COVER
HEAVY GREASE 13AFFLES IN PLACE
OTS LEACHFIELD RUNBACK
EXCESSIVE SLI S FLOODED
SOLIDS C✓A, Y VEI2 OTHE Tt (EXPLA,:IN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: