HomeMy WebLinkAboutSeptic Pumping Slip - 754 BOXFORD STREET 7/19/2017 {4`' Commonwealth of Massachusetts
(1, City/Town of No.Andover
`� u) System Pumping ecoid
,-
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 clays from the purnping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the {j
computer, use I _ &)_XQ 1
/
only the tat)hey Addre�s
to move your No.Andovor Ma 01845
cursor-do not
use the return Cityrrown Stake Zip Code
hey.. 2. System Owner:
Ali
Name
Address(if different from location)
y _ t f wN O t t��l,"f G�s`�6"D:�d q &
Cit mown StatefYl t H ii 11 � A6 1 fde
`Te"leplione Number
B. Pumping Record
1. Date of Pumping f c C. ._.._._. 2. Quantity Pumped: f �f
Date Uallons
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? Ej Yes ❑ No
5. Condition fystem:
6. Systet u ped B
Name Vehicle License Number
S ewart's Septic Service
Company
7, Location where contents were disposed:
Ma 01835
Stewart'sere-treatment Plant, 20 So. Mill Bradford,
........ ..........
Sig ture of Hauler Date
n
-af R itity Date
" -
U>"76rm4.dac-43106 System Pumping Record-Page 1 of 1
i •i. +, +�P`'prrl.. tli��PlilYi�uKi t � SSE.4y,
t I� q'.�U v "%7�t�dr( A114�P7�tt4i
5aKfait �1JMit
r y
4 q
n 3 "t�b n^ vS� ;�1h� ' a1�IVIIpia �
t, 1 1� I ht 4 !. !1 ��• 5 N� � I . v
III .ur tJY —LP
•,IrY��i'is�
,, , o mon ealth of Massachusetts
!,,
C)ty%1'own of. ORTH ANDOVER MAS To
' ystem Pumping Record ,
Form`4':` - ,
DEP has provided this form for use by lopal Boards of Health. The System Pumping Record mu;
be submitted to the local Board of Health or other approving authority,
i
A.Pacillty Information
€ 1, System Location ti
City/I own State Zip Code
2, System Owner
r .r
' Name
Address(If different from locatlon)
City/Tcwn State Zip Code
r
i
Telephone Number 1
f
r
Pumping Record
1. Date of Pumping Date 2, Quantity Pumped: Gallons
3, Type of system; . . ❑ Cesspooi(s) V Septic Tank ❑ Tight Tank ;
I
" �•❑ Other(describe): E
4, Effluent Tee Filter present? ❑ Yes ❑ No if'yes;'was It cleaned? ❑ Yes ❑ No
5, Condition of System.
m Pumped By.
2,6
me �{ `Vehicle License Number
Company ' V
7, Locatio where contents were disposed;
. Y,
S gnatum- Hauler , pate
hbr z,gov/dep/water/�pprovalsA5forms.`htm#Inspect •'`'
cf
System Pumping Record-Page 1 of t
EC IV
,
a •r�, J{//// m ,.^''W,,,. � I r yg, C t m pIQr 1cyr�� �>V,, , ;l'.
y�ryry�/r Cyy y,��Y gy p ( Q+y/^�py q
TOWN
V l�7 V !A EWY�1 `�� !l 1✓4w/('W,GtY +',�..w,... �w M ....,,,,„ ........., ..,..,,..,,�,....�,,
// Yd
mm
r
,
r "
1
y� ,«r{,� w� 1�wrwrlaa x 1`d+p✓+rwa°
rvg Vf ,dr✓r^4 vr�w��r ✓RWW°r°►r�rG , .i
0000 Nay rrioN ,,. , I'VC I �rC7vrx
moom
C)nf R'
XP!„AfN
Cw"` p
1 N Mwrm'� Wer M W Y co ,l e t'r�rl� I I� ��x ,. /� w Pl. ♦,.�,/..•/
Y ,
1 ( I S
r P e
OWN.,OF NORTH ANDOV. ER
SYSTEM PUMPING RECORD
"A �ly�ti'l � T +wrVlj !kM�
$YST M OWNER&ADDRESS
SYSTEM LOCATION
(example: left froatofhouse)
TPA 6�rl Y
}b � •} 1,
PR;
Ui r.t�t4��.,-.; rtiF ir,� rr�� r ,• ��(4w.,�; ryi h ...., .. ,_ . _.r.,��' ..
tr
VMPIN
G QUANTITY PUMPED �� ,GALLONS
lul
,"i.' "+���tar��# I!��ah���¢rl�t%i1�ta
i `f�'"4r' ' 'iSf't!(F'b,, SSP4lJL: NOa.
. .;..., "YES SEPTIC TANK: NO YES • °"`
9T.�l '����14����;j!'d
;;,t ti Y F "x k ' ,' ,BTURE OF SERVICE.NRO UT INE EMERGENC
„ y
t 1+► r r
re 11
q PI V
Ct� y
r
1rAkf }4# ,Er�Tf Sas�r ra
,��r > OOOD CONDITION` FULL TO CO
VER
HEAVY GREASE
BAFFLES IN PLACE _
ROOTS LEACUFIELD RUNBACK
EXCESSIVE SOLIDS
FLOODED
E P SOLIDS CARRYOVER OTHER (EXPLAINio
)
k3 Q
a
w.°f s' C f 1:.!»+3 � s ., # t {..Ytfir+r k.• v + +kA;z 'S
��{ �ti��q�i"�� ll�rt *��^�y�►fr��i^R i f'�b"#�, ��'°� arvT�y,#,+^., � .
r
k'blt 4' nl� r'> ray � r'`ar r Ir,.rl� o
4��# h�j�y+�n A�6'��w,�wf�� r I�''"i-'M`n"'"'".k'°'AFS "?',,"�1,!*rFE/�'!�',,T�• " /
y� l
"0"
'fir � �bs�` � S? xr� (°#�rr,lhh � f#•r (+ r +r-
r }}
V.�0 Q11
^��[.�.' w
WW •rM*
i
q. # r� '