HomeMy WebLinkAboutSeptic Pumping Slip - 1060 SALEM STREET 8/29/2017 Commonwealth of Massachusetts
City/Town of
Sem Pumping Record NORTH A►NDOV ��� i f�.�i ��
����I �,� i�
Farm 4If
�r
CEP 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 CNIR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer.use _ �G! G�Gyr'�
only the tab key Address
to move your 141 � , "r' ✓ '� __ . _ ''� �'�
cursor-do not ------.—_..-_.-- .-----..._.
� ....__—,_.,_-.__ --...----__.__ Skate Zip Code
use the return City[Town
key. 2. System Owner:
Address(if different from location)
-._... —
City/Tawn State Zip Code
Telephone Number
B. Pumping Record
1. Cate of PumpingCa e/�f�.�/7 2. Quantity Pumped: Gallons ._--
3. Type of system: ❑ Cesspool(s) Septic Tank [l Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System;
6. System Pumped By:
L
Name .__�-- Vehicle seee Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•gage 1 of 1
Commonwealth of Massachusetts
City/Town of NO. ANDOVER
System a i
Farm 4
DEP has provided this form for use by local Boards of Health, her forms may be used, t the
information must be substantially the same as that provided her .- „f�Qk , RAi�� fl�f�is��forx ;� heck with your
local Board of Health to determine the form the use. The S ste ! . Nn, : � ) e submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms the 1060 SALEM ST
computer,use .11-060 _..._._..._ .....,___..
only the tab key Address
to move your NO. ANDOVER MA 01545
cursor-do not _.._._..,., _._.__....
use the return
City/Town _... State Zip Code
key. 2. System Owner:
LISA WHITEHEAD
Name
Address(if different from location)
City(Town State Zip Code
Telephone Number
_ ..-
----------
B. Pumping Record
6/11111000
1. Date of Pumping 2. Quantity Pumped: __.,,..._...,_.. ...._ ...
Date Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other(describe): WNO
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
James H. Currier H79406
Name Vehicle License Number
J's Septic& Drain
Company
7. Location where contents were disposed:
I
GLSD _
......
,/ >
� a 5/1/11
Signature6f Hauler Date
t5form4,doc•06/03 System Pumping Record-Page 1 of 1
�L\ Commonwealth of Massachusetts
City/Town of NORTH AN MASSACHUSETTS`
System Pumping Record
Form 4
EI a.
DEP has provided this form for use by local Boards of Health The System P mping R Lord must
be submitted to the local Board of Health or other approving Utho"AY
A. Facility Information
TCAPYN OF`NOR,"M
�ihpjj'Fl DEPAR M�,
Important:
When filling out 1. System Location:
forms on the
computer,use L
Y the tab key
cursor-do not Address
to move your
use the return City/Town State Zip Code
key. 2. System Owner:
—---------
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) j Septic Tank ❑ Tight Tank
El Other(describe): —-----------
4. Effluent Tee Filter present? R Yes No If yes, was it cleaned? El Yes [I No
5. Condition of System:
j
6. Py tern Pumped By:
Na a
Vehicle License Number
Company
7. Location where contents were disposed:
4 lo ) ti
Ue2—�, Date
Igna. a of H ul6r
http://www,mass.gov/dep/water/approvals/t5forms,htm#inspect
t5form4,doc-06/03 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts ..
City/Town off
System Pumping Record
r: Form 4 4 2,00b
DBP has provided this form for use by local Boards of Health. 111*e10400wPurnping Re„ord must
be submitted to the local Board of Health or other approving a thorlty.
A .Facility Information _
Important:
When 1. S ste L cats
forms onlitnly out y
e C
computer,use �.
only the tab key Address
to move your '1 `�
_ .
_ _
cursor-do not ---� ------- ---.
GityJTown State Zi Code
use the�retum P
key.
, 2. System Owner: IN
_sA
Name W __.....
in Address(if different from location)
Git
y/Town St �� �i C d
��
Telephone
Number
B� Pumping Record
1. Date.of Pumping Date ............... 2. Quantify
'Pumped:
Gallons
3. Type of system: Q Cesspool(S) [wept ank ❑ Tight Tank
❑ Other(describe)` __ _ _...
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condit* n of Syste A
-------------
6.
Y Y
�, �. - � Vehicle License
Number
Company
7. Loc ` n wwhere ontents 1er di ed:
.�
Sign re ruler a _,.
Date
http://www.mass.gov/dep/wate /approvals/t5forms.htm#inspect
t5form4.doc-06103 System Pumping Record-Page 1 of 9
TOWN
SY TEM PUMPING RE
° .
o t""p
DATE: MAR 2 2 2005
0
,FOWN& & ANDOVER
SYSTEMtDWiVEi� � AI)I�ItESS SYSTEM LOCATION
(example: left front of house)
IDA.TEI+'PUMPING: �' QUANTITY PumPEID : GALLONS
CESSPOOL,: NO Y
ES SEPTIC TANK: NO � YES 'l
NATURE OF SERVICE: ROUTINE� . EMERGENCY
OBSERVATIONS. H
GOOD CONDITION F"IJI.L TO COVER
(HEAVY GREASE BAFFLES IN PLACE
ROOTS LEAC +IELD II.iJNBACIC
EXCESSIVE SOLIDS FLOODED
SOLIDS C I2 ID
RYOVET r R(EXF
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
I TS:
CONTENTS TRkNSFE RREID TO: .,..., Lowell WaSte,
TOWN OF A/
.....
....,.
E
SYSTEM P G RECO
T 19 2004
DATE:
..ICOWP 8 OF i MFYl I—r A[dDC;4.IFR
�dlm,�I.CP-4 i Kiwi°ati4�Y f✓f� h��
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
( cv;�lc U .
DATE OF PUMPING: QUANTITY PUMPED : GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTE,NTS TRANSFERRED TO: G.L.S.® Lowell ante
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE
a
n •
SYSTEM OWNER, ADDRESS
SYSTEM LOCATION
(example: left front of house
a
.. �.
, P
. fF 1o�M9;A" p
DATE OF OF PUMPING: r r : �� `
,... QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO -YES
ATURE OF SERVICE: ROUTINE
'EMERGENCY
OBSERVATIONS.
E f( I{
GOOD CON,D►ITTON.
HEAVY GREASE FULL TO COVER
ROOTS -----" BAFFLES IN PLACE
EXCESSIVE SOLIDS LEACHFIELD RUNBACK
SOLIDS CARRYOVERFLOODED
OTHER(EXPLAIN) "
SYSTE _.
PUMPED BY;
°
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r ,� ,�14rS r 13• ,
r '�COMMENTS:;
t
5
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r.!QONTENTS TRANSFERRED TO:
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APR 4 2001
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