HomeMy WebLinkAboutSeptic Pumping Slip - 1773 SALEM STREET 8/16/2017REECE E
Commonwealth of Massachusetts
City/Town of AHH / ?O'!)
System Pumping Record NORTH ANDOVERHorinwHANnovisz
Form 4 LHiLI I I r
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 oul 1. System Location:
forms on [he
computer, use
only the lab key Addr
to move your
cursor - do not
use the return
key
i5fortn4 doc• 03/06
City/Town
2. System Owner:
Name
Ac171feSs(iIdifferent from location)
Cily/Town
0 igq5
Stale Zip Code
Stale
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping
3. Type of system: LIJ Cesspool4P
Bradford, Ma 01835
(97 074-2382
4, Effluent Tee Filter present? Yes [No If yes, was it cleaned? EJ Yes 2 N
0 Other (describe):
5. Condition of System:
6. System Pumped By:
Wind River Environmental
Name 163 Weliteni Ave.
Gloucester, MA 01930
Company
7. Location where contents were disposed:
gnr(ot Hauler
Signature of ReceivingFacility/
lb, Pumped: Gallons
r-St Tight Tank El Grease Trap
.__....
Vehiclerlicense Number
Date
Date
System Pumping Record Page of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
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 Pumpin9Record must be submitted to
the local Board of Health or other approving authority within 14 days fro theirptias
accordance with 310 CMR 15,351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key
Add
City/Town
2, System Owner:
Name
State
?014
TOWN UF /ANDOVER
HE ALT DE P\V Nq ENT
(nPLS__
Zip Code
Address (if different from location)
City/Town
Stat
Zip Code
Telephone Number
B. Pumping Record
3
1. Date of Pumping k) i3 2. Quantity Pumped: OC)
Date Gallons
3. Type of system: El Cesspool(s) (Septic Tank El Tight Tank E] Grease Trap
[11 Other (describe):
4. Effluent Tee Filter present? 0 Yes
5. Condition of System:
6. System Pumped By:
Name
Company
7. Location where contents were disposed:
Signature of Hauler
Signature of Receiving Facility
If yes, was it cleaned? El Yes El No
Vehicle License Number
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Important:
VVhentIllIng out
forms on ine
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Name
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
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 thepurnpe
nir
accordance with 310 CMR 15,351,
A. Facility information
1. System Location:
j?? .,‘,?1 574
—
Addre
Cityrrown
2. System Owner;
-Ye-119z fcele-5
Address (if different from location)
"CityrriTy-n
13. Pumping Record
1. Date of Pumping
3, Type of system: 0 Cesspool(s) a-S11-)tic Tank
J(.„IN ?:(112,
TOWN OF NORTH ANDOVER
HEALTH DEPARNIMEENT
State
State Zip Code
TeIpt'One Nume/berf2, 23.
Ei Other (describe): .. 1.1 • •
4. Effluent Tee Filter present? 0 Yes 0 No
5, Condition of System:
_ — -
2, Quantity Pumped:
lions
0 Tight Tank D Grease Trap
If yes, was it cleaned? El Yes UNo
6, System Pumped By:
CA) . •._
License Number
Name
Company
7. Location where contents were disposed:
MA;- - —
Date
Signature of Receivin9 FaCillly Date
t5forrr4.doc- 03/06
Sys(ern Pumping ReCOrd Pagq 1 Or 1
..1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
TOWN OF NORTH ANDOVER
FIEALTH DEPARTMENT
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
1. System Location:
i'773
Addres „--
:t\n, An( OVCX MA
City/Town State Zip Code
2. System Owner:
cn
Name
Address (if different from location)
City/Town
Stale
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping
3. Type of system: El Cesspool(s) [1'Septic Tank [1 Tight Tank L] Grease Trap
D Other (describe):
4. Effluent Tee Filter present? 11 Yes LA/No If yes, was it cleaned? Yes CeNo
5. Condition of System:
00(
6. System Pumped By:
'On GO
Name
IS1 17),11C:c
Company
7. Location where contents were disposed:
ipavvich Water
Treatment Plan
Date
0
2. Quantity Pumped:
Signature of Hauler 0,1A 01 q3
Vehicle License Number
Date
Signature of Receiving Facility Date
/500
Gallons
15form4.doc• 03/06
System Pumping Record • Page 1 of 1