Loading...
HomeMy WebLinkAboutSeptic Pumping Slip - 9 TURTLE LANE 5/16/2013 RECEIVED _ :, Commonwealth of Massachusetts 2 City/Town of No Andover [HEALTH � E System !�1 rd r NrDRwrH ANDCJR DEPARTMENT 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, 9 Ar / use only the tab /� / w key to move your Address cursor-do not No andover Ma use the return City/Town State Zip Code key. r 2. System 0wne,7 J . Name ----- Bam Address(if different from locations x� — City/Town State Zip Code Telephone Number B. Pumping Record m 1, Date of Pumping � 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) ,,, Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? M Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: "m 6. system Pumped By: Name Vehicle License Number _Stewart's Septic Service Company 7. Location where contents were disposed: ,zf"�Nart s Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 ignature of HauleDate Signature off,1eceiving Fdcili(�i- _ „ Date t5form4.doc-03106 System Pumping Record•Page 1 of 1 RECEI VED DRi R M SSS m ACH'USETT R 8 C' 200 0 CCS ' �• t'�1�.V.0•�ly,i�. i.Il.�1��i�Jrl�t���f'e��'i��.l;lyl�i.y,�•�f� �..t'. � OEP.hdf provldvd Icily 1prr7 ter waa wy �rur 808Icr�aror ()'° V�NC���..)FNOp��c'B Ar�9l�d�T Ja r :wn'!lllad t0 U1G !Of 11 6Cert: c'r n aG�l1 G7rCIrYQt 1" t I lnpnfy . Fac111ty inlorf l`aftn p 77 '�,�� '``''sw�,f;•.�',,`rf2 �, Sya(amY�7��rn�e�rf�.,} ' , r , �' r'••4drµ� frt4V(►rini rpm buVan) II•b�nOnY f;,mOYf �/ y Pumpln ord Ir Q ar'. ' JXPQ 91 1X)(om;.. L7 C499�001( r •�,. �1 Svpl•c rens " 10'h9r ( SSCfibB� EfT;um.TvarFl8e(p, L' Yos Q"r,o . f C.o ` an' y /..�, ,r�� Yfly l �/,Ir f'!,l•(. 4' r. � YY�, p ,{, ('� �.. �...- ------------- 1 • Y l,f vmpod 8y:. •�I' wn vi 'r•�(.�,'�'�� 7• l7�h .�rh�r�,oor�lanE :ward oi5pmo: / •JIY i n. ,.r S r11lLU �.;� Nw,ma�J, ovlda hvsivilspflr4ye�s�{6(orma.r, marn9�©ci Y4SM/ r 7 � "Y o. •} ( �,�,,., ,. , �,.ry ..n i tt}#4 d 5! r }Ir�` , +�b w r���I+G P��rltliUBpp?,�t"it��rr Y r r ti �7�5�� �• w i r � r �C�US QKTH iFrj 4-z r✓V t, ,; TS A 1 t inti�YgMA `&;. P�...� ixJtdwt ,1'� Ivt i "+ + tniJx ' RQ .$w ' "kYk+' s'Y� 1 w Y; � tJRr)j/yi4v r h S, rl r'.Ir r1 < r,i DBP:,has'provlded this form for use b local Boards of Heap c� y ? �p�t5y� ,j�' } pBrrg R"ecord (must 1' :-be submitted to the.locar'Board of Health or other approving euthr, fty. 3 A� Facility.Inforrfttion i 'ii 7q�!AA'wl foung out - 1 r System Location,';r . , �'Contputef asst , r only the tab key Address to move your cursory do pot`r Ciky/1 own tak Code._._ U"the return,: a Zip 4 SdK�� ',il 'Pt. { + rla a�lrl r4 tart rPi Name Address(11 different from location) Cltyaown State e u 2 � 1 Telephone Number �umptg Record , . r y�'+ al "e i✓( fa�aiti,t,y�r '�e''dlc.Y�rJ���Y+;�I�{,+G 9 Dat�`ofPumping oat t° 2, Quanta Pumped: 5 - p Gallons w.' Typa Qf systarn: ❑ Cesspool(s) � Septic Tank ❑ Tight Tank (� other(desoribe), uent Tee FiPter present? ❑ Yes No If yes, was It cleaned? ❑ Yes ❑ No i Jy M Mt e�dh(��,/'�# �.'•+u�r vN(G�'r B ° ,t •",,Contlitian'of Syst m,'#t / � .. ... t ,; M t, ,�""�tl r.a it 1, Q✓t.A fi a YS l"'Y f!�r f .A •"r-,fr' Y LAY .., Y-^' r :y:•. ,1 ri, �+I Y"'�xl:Su r Alt.r�•�ti!,iC 1,1� t � . Sy t;m Pumped ay; ' „Vcte Lfcen�a Number -V4 fe r 4 t �✓ lrY•�.ti ., 0,i+l+sw Sy':� r�w}�,1�(ty�,` Ir.tY j �.lt B, 1" r.�{il"��W� �.0:�y� 'r'k Jl4�.t t.rW.,4;� ij:�,r.,t,.•. f1 f.Yl J.. �'7,J'.,LoCa6On.wh04Q ontents,yvera`di;3posed, .. l old r5tl g r.r11 f•rtr, l`i��+ ,.l .1.! ,' ri,'r.t+•. 1 Date httpJ/www,oras" .go'v/depJwater/approvals/t5forms,htm#Inspect t5fwAdocs OW6 r System Pumping Record r Page t of I TOWN OF NORTH AN'DOVE; , , .. UA 11 .,, SYSTEM PUMPING UCO}tJj SY�T M OWNB'K ADDK,BSS SYS7EM LI"' A I )IIN AQ DATE OF PVRMNQ: ...., ,.: _.._QUAN17TY PIJMAED; �.4 . •.... .. I . . ,. 5op'oc Turk: No 1e • � rwuwwnsb�y r NA ruRu op SBRvfCE: RUu'rE l4✓' �MkRU�NC"1' CEIV ED OOOD carerrioN ........ FuLLJYJ (.OVER JUN3 2005RuvY 4�B BA."'LB3 IN Pl ACL, WT13 .,.,... LBhCKF"t61,,DKUNBACK r OXCUSIY6 SOLIDS ..._.. PLOODBD Hc_r�4�-�.�i c.�r 4�Ic�,���� r�L.�,4.�. -SOLID CA R.R YO YBR' p`f iE R EXPLAIN � .�.�., .._ . �_..,._.. �_.....�.�.�...�a... ,.,..�. CPO— a. 5r►��► Pwnpcd by _-t�...�',C,�, y.�`..�.,... .T.SIG,.., ,. w'uMMBNT �:uN r�N"f�� rt�►,N�r'�r��u �'�, �•t4 {.:, �f/1�rrYJtiftY{C��p�. r Ir4$ �, +!'! 1 1.`!� 44 'u`(\ r d,rfr'.4 1• .dr, I r/1 r•,I.f. V. ��I'' �+i t r111 �y'rfl'N�gad+11�1 r�.�'o•1,'n;I o. low@Ft EEw EE I �*w . V� I I ll`�k•l I d✓ I p UA 1^a , S y 8 E M P U M P I N UR-P.( O K.. TOWN OF NUaH AMWER � HENJ d �R �,!7 3i CJs — . . _.� _ 5 r� __.M�,�t"• ';� a`�,;;"mm .. ....�. �.a_ �._�. _. ,. .. • +�, 'cam.- ...�! � . ..� �;��.: ..� � ,�'�'�„�� C7� �o�..JS�-� OAT! OP PVMYINQ", w, _QUANTITY PIJMPE'p t'tssP'pU�' N 'yam u'c>Y r x KQQT ; �ir4CK 1 t p K UN n�'F• MUMS SOGIp8 ,,.... Pl GC7D�D $OLtDCAMY0YAK O1'NER EXPUIN e'uMA-I�NT�. r, •rr,rw Y n r r.,Y+wrr ,w f Y/✓d I 1, I"C7' OF NORTH ANDUVk:'�, SYS M PUMPINQ REcopli.) UA SYSTEM OWNER dr ADDRESS sysT> M LOCATION . �-�we, DATE OF PVMPiNU: // .. ...!f 7 �4i,l1 ANTrTY PUMPED:-7 , ....,.,... S00c Truck: 1yU YES NA rURE OF SERVICE: KOu'rt.NR ObSbRVATIONS: <X30D CONDITION FULL 'ro COVER HEAVY GREASE ROOTS _. I3AFFL 8S IN Pr,A( 1, LBACHFIaD RUNBACK IMBSISiVE SOLIDS'-.- FLOODED I � SOLID CAKRYaVERn,,,. . OTHER EXPLAIN *atom Rwnpod by ser rrrQ. �-'UMMENTS. CUN MNTS rKANSFhK"D 1.0s`( r Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS, System Pumping Record Form 4 , DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility information Important: When tilling out 7• System location: farms on the computer,use only the tab key Address to move your1) ��a cursor-do not City/Town State ZIp Code use the realm key' 2. System Owner:, ce Name Address(If different from location) Cityrrown state Zlp Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallo 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 1 I '7 "► 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it clea d? -1 Yes E3 No 5. Condition of System: , i - 0 6. ,System Pumped By:,FICIffOCK ams Vehicle License Number ' Company 7. Location ere contents were disposed: Signature of Hauler Date http:ltwww.mass.gov/deptwater/approvalstt5forms,htm#lnspect t5form4.doo•06/03 System Pumping Record•Page 1 of 1 i TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD 3 DATE: 11z, SYSTEM OWNER & ADDRESS SYSTEM LOCATION (e:�#rnple: left front of house) "9 Ali( ....... a ill n G: GALLONS DATE OF PUMPING: QUANTITY PUMPED CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER BAFFLES IN PLACE HEAVY GREASE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: