HomeMy WebLinkAboutSeptic Pumping Slip - 336 BOSTON STREET 7/20/2017 Commonwealth of Mass chu_petts
City/Town of /A//O
System Pumping 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.
A. Facility Information
Important:When
filling out forms 1. System Location
on the computer, CZ j ^° µ I a I D
use only the tab
key to move your Address
cusor-do not
use the return City/Town State
key. P(904e)R1
i l
2. System Owner
&,-.MCA5
Name
reran
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record .
1. Date of Pumping — 2. Quantity Pumped: -d
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank [ Grease Trap
® Other(describe). _ --._-.__ _-
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes Kl
5. Condition of System:
6. Syste P ed By: }
am Vehicle License Number J
ewart's Septic Service t
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant 20 So. Mill Bradford, Ma 01835
i
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts HNED
City/Town of North Andover
System Pumping Record AUG �� ���
r Form 4� "tt""r" vi�.�c.i��ax��IHMfllwt�"E,[i,
is form for use by
Boards of Health. Other forms
DEP
information provided
st behsubstantially the samelas that provided here. Before using this d' but the
, be use
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
on
t e c the tab' 1. System 1ocatlon� -.
filling
key to move your Address
cursor-do not North Andover Ma 01886
use the return Cityfrown State Zip Code
key,
� 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
-= 2. Quantity r-
1. Date of Pumping Date Y Pum ed:p 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 By:
Name �4. 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-"---
auler _ Date
Signature of Receiving Facility Date
t5form4.doc•03106 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts � E
x w City/Town of NORTH ANDOVER
System Pumping Record
q. 1
Form 4 TOWWN OF NORTH TH NDOV:R
l REA13"tt DEPARTMENT
lWlt l"T
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
urlsthe e only computer,
ng out forms 1. SystemLocation: � � �
.J tea
y _.......... _........._...
key to move your Address
cursor-do not NORTH ANDOVER Ma
usethe return _.._......... .._.._ ._.....__ -.. . ... -- .__...._... .........
key. City/Town State Zip Code
rab �
2. System Owner: J
U1 ........_.._ _ __ _ _.... _
Name
r
Address(if different from location)
City/Town State Zip Code
..........
Telephone Number
j B. Pumping .Record - -- m
1. Date of Pumping 2. Quantity Pumped: 1500 ......
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 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
i
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.1oc•01106 System Pumping Record,Page 1 of 1
Commonwealth of Massachusetts
City/Town of No andover
System Pumping 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
A. Facility Information
Important:When
filling out forms 1. System Location,.,.
on the computer,
use only the tab
...........
key to move your Address
cursor-do not No AndoverMa
the return
use
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
.......... ......
cit- y[-Town State Zip Code
-----------
Telephone Number
B. Pumping Record
e
1. Date of Pumping Date 2. Quantity Pumped: Gallon-s
3. Type of system: F-1 Cesspool(s) [Septic Tank Ej Tight Tank F1 Grease Trap
R Other (describe):
4. Effluent Tee Filter present? 0 Yes Flo If yes, was it cleaned? R Yes El No
5. Condition of System:
b-6 ticf C
..............
6. P led By:
em' YMP
Name Vehicle License Number
-Stewart's Septic Service
Company
7. Location where contents were disposed:
tewart's Pro tri' tment Plant, 20 So. Mill Bradford, Ma 01835
Signatur of u r Da
Z
Signatu o Rec iving Facility Date
t5form4,doo-03/06 System Pumping Record Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSAHt
System Pumping Record d. .
Form 4 4��..I 01
DEP has provided this form for use by local Boards of Health. Te 'fir mus
be submitted to the local Board of Health or other approving aut
A. Facility Information
Important:
Men filling out 1, System Location: r ,
fomes the A� � __.....
computer,use
only the lata key Address
to move your —_—_-- ) Ay
µ
cursor-do not City/Town State Zip Code {
use the return p
key. 2, System Owner: \\
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. .Type of system: ❑ Cesspool(S) M zSeptic Tank ❑ Tight Tank
Other(describe): —r—
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5, Condition of System:
6. te'm//Pumpei3y:
me Vehicle License Number
Company
7, Location where contents were disposed:
Ra
IIAtx) '
gnatof Hauler Date
•r.
http:l/www,mass.gov/dep/water/approvals/t5forms.htm#lnspect
t5form4.doc•06/03 + System Pumping Record Page 1 of 1
Commonwealth of Massachusetts
City/Town of North Andover
w°
As
2System Pumping Record
Form 4 TON C^NORTH
H AN)OVE
R
HEALTH DEAR'r N rP
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 Loc tion:
forms on the
computer, use — _ Y- �,�
_._.._..-. ._....._.
only the tab key Address — _..____. ..._ _........
to move your N.Andover Ma 01845
cursor-do not _.._. ___..._..._..__......_......_._—
use the return City/Town State Zip Code
key. 2. System Owner:
Name
" D Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record I
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? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
CX36-C"E)rd-
6. Pstern Pum ed By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Ste art's
_Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
.-
e o Hauler Date
Signature of Rece vi F t ._...._ Date
t5form4.doc•06/06 System Pumping Record-Page 1 of 1
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Commonwealth of Massachusetts
a� e City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
Form 4
N DEP has provided this form for use by local Boards of Health. The System Pumping Record rnu,,
be submitted to the local Board of Health or other approving authority
.
A. Facility meti
Inft�rc�-n—
Important:
� � � '
When filling out 1. System Location: /�
farms to the -_ __. _.__..-.. c �! / Q ., TOWN pI
computer, use � Iii rbC Ikd��l i&I/�,I'd!9r�v��i
_ ...__ � �fe �4
only the tab key Address A". . !?I' I I-A 6�sr PAR h�I:.... .. „
to move year
cursor-do not ..._ =21 �i.�..._._
----
use the return City/Town State Zip Cade
key.
2. System Owner:
Name
---
Address if different from locattan) --
-.
ityfTawn State Zop Cade
Telephone Number
Pumping Record
1, Date of Pumping ._
p 9 date __._,. _..._-_,-- �. quantity Pumped:
Gallons
3. Type of system: [] Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? FA Yes No' If yes, was it cleaned? ❑ Yes C] No
5. Condition of System:
5. Sy em Pumped By:
Name
_,. .. Vehicle License Number
Company
i
7. Location where contents were disposed:
fit /
Sp ature of Haulf Cate
http,,//www.mass,gov/dep/water/ap"provals/t5farms.htm.#inspect
t5form4.docw 06/03 System Purnping Record - Page I of 1
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
til'STEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
D,,v'I'E OF PUMPING: � QUANTITY PUMPED// , 'd G A L L 0 N S'
C:4w55f'00I.,: N0 YES
SEPTIC TANK: NO YES
N,.NTURE OF SERVICE;: ROUTINE EMERGENCY
U[ISERV:�TIONS;
GOOD CONDITION �"��� FULL TO COVER
I~iEAVY GREASE BAFFLES IN PLACE w "
ROUTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
�'S'1'F^,1 P U M P C J E Y: �'Y' .- _ �� ' 'Ti
'UNI NI ENTS:
TRANSFERRED 'T'O:
'T'EM PUMPING RE
FORM 4- SYSCORD
cu
SEPTIC & DRAIN SERVICE
E
107 FOREST STREET;MIDDLETON,MA Q 1949
(978) 774-2772
COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
SYSTEM OWNER: Lk SYSTEM LOCATION:
� f r
C tyid e`
DATE OF PUMPING: �%' QUANTITY PUMPED: ,� GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO F7 YES �r
SYSTEM PUMPED BY: CURRIER SEPTIC chi DRAIN SEi R'VICE4
CONTENTS TRANSFERRED TO: L`
i
DATE: — I INSPECTOR: q 'tf _—
ti: