HomeMy WebLinkAboutSeptic Pumping Slip - 54 TUCKER FARM ROAD 10/26/2017Important:
when filling out
forms on the
computer, use
only the lab key
to move your
cursor - do not
use the return
key.
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
d must ch submitted k with your
to
local Board of Health to determine the form
they au authority y within 14 dayse, The System from tghe pumping date in
the local Board of Health or other approving
accordance with 310 CMR 15.351.
A Facility information
System Location:
Address
City/Town
2. System Owner:
l` f"4 r cy
Name
State
Address (it diKerent from location)
City/Town
B. Pumping Record
Date of Pumping
Type of system:
State
Telephone Number
2. Quantity Pumped:
Date
❑ Cesspool(s)
peptic Tank ❑ Tight Tank ❑ 'Grease Trap
Zip Code
Zip Code
-r
/1 e") C-
Gailons
El Other (describe):
Effluent Tee Filter present? ❑ Yes
Condition of System:
System Pumped By.
Name
Company
Location where contents were disposed:
Signature of Hauler
Signature of Receiving Facility
if yes, was it cleaned? L_J Yes U No
Vehicle License. Number
Date
Dale
I5forrn4.doc^ 03/06
System Pumping Record • Page I of 1
Important:
When filling out
forms on the
computer, use
only the lab key
to move your
cursor - do not
use the return
key.
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 the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Lo
ation:
•—•
2. System Owner:
(.:),<.:*!-'
Name
Address (if different fr-orFt o
City/Town
tel°
B. Pumping Record
7 --
1. Date Date of Pumping
Date
3. Type of system: Cesspool(s)
Li Other (describe):
4. Effluent Tee Filter present? Li Yes LI No
5. Condition of System:
6. SystP mped By:
Nam 1
(HOU
Company
7. Location where contents were disposed:
ptdr aul
ature of Receiving Facility
4:245'7'
Stale
.(?) /rfr
Zip Code
Zip Code
State
Telephone Number
2. Quantity PumpedGallons
tic Tank ri Tight Tank H Grease Trap
If yes, was it cleaned? Li Yes 0 No
Vehicle License Number
Date
Date
15form4 doc• 03/06
System Pumping Record • Page t of
E
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVE
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.
JAN -5ZUil
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
A. Facility Information
I mportant:
When filling out 1.
forms on the
computer, use
only the tab key
to move your
cursor • do nol
use the return
key.
System Location:
Address
City/Town
2. System Owner:
6e,i1-1\
Name
Address (if different from location)
City/Town
j
,et.71,44-
State
Zip Code
State Zip Code
6 Ye"— e
Telephone Number
B. Pumping Record
_R--
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: 0 Cesspool(s) [G—tic Tank u Tight Tank 0 Grease Trap
El Other (describe):
4. Effluent Toe Filter present? 0 Yes 0 No If yes, was it cleaned? 11 Yes Li No
5. Condition of System:
6. System Pumped By:
Name
Company
7. Location where contents were disposed:
Signature of Hauler
bowri)-nre-i-7,
Signature of Receiving Facility
15form4.doc• 03/06
Vehicle License Number
Date
Date
System Pumping Record • Page 1 of 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
CityfTown 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 fro
accordance with 310 CMR 15.351.
A. Facility Information
1.
System Location:
Address
City own
2. System Owner:
VeZ4 2-A4/Ckn
Name
Addrei(ifdifferent from location)
6ityfrown
State
JUL- Cl(
10
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Zip Code
State Zip Code
resrc
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: 0 Cesspool(s)
Date
/ 2. Quantity Pumped:
Gallons
P-Se-p"7-tic Tank 0 Tight Tank 0 Grease Trap
0 Other (describe):
____
4. Effluent Tee Filter present? p--ies 0 No
e ,
5. Condition of
6. System Pumped By:
/7C--
Name
Company
7. Location where contents were disposed:
Signature of Hauler
Signature of Receiving Facility
t5form4.doc. 03106
If yes, was it cleaned?
/1_3
Vehicle License Number
Date
Date
Yes LI No
System Pumping Record • Page 1 of 1
Commonwealth of assac
City/Town of
System Pumping Recoru JUL () 8 ?009
Form 4
\NN oF NORII ANDOVER,
hE
DEP has provided this form for use by local Boards of Health. Other forms n Tb-e-AErgiTiEUPtAT-7"LET 6-—
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 Location:
forms on the
computer, use
only the tab key Address
to move your
cursor - do not
use the return
key.
ck, r
AJC C ArL._ lakAS.1. \ar
City/Town
2. System Owner:
0 11
Name
A A
State
Zip Code
Address (if different from location)
City/Town State
8- (6
Zip Code
Telephone Number
B. Pumping Record
-3
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: 11 Cesspool(s) Er.geptic Tank Eli Tight Tank Eli Grease Trap
LI Other (describe):
4. Effluent Tee Filter present? 0 Yes ErNo If yes, was it cleaned? 11 Yes 11 No
5, Condition of System:
rc
6. System Pu ped By:
Name
'1^1
Company
7. Location where contents were disposed:
/t/Le8
Vehicle License Number
Signature of Hauler
• L.S.D.
w ence, MA.
Date
Signature of Receiving Facility Date
t5form4.doc• 03/06System Pumping Record • Page 1 of 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 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
1. System Location:
C \,c
rc..\
Address
CIOV
City/Town
2. System Owner:
Nr)1cn
State
) .2)
Zip Code
Name
51-1 C Y-Y1
Address (if different from location)
1\)06\(\ AnclovX
City/Town
1^A
State
q 77C
Telephone Number
Zip Code
5
B. Pumping Record
1. Date of Pumping
3. Type of system: LJ Cesspool(s) D"Septic Tank
El Other (describe):
Date
7 2. Quantity Pumped:
i 500
Gallons
E1 Tight Tank
4. Effluent Tee Filter present? Yes N(No If yes, was it cleaned? Yes 111 No
5. Condition of System:
6. System Pumped By:
jiff) Gulkkl)
Name
11 C Env) colarntq
Company
7. Location where contents were disposed:
LT-Li()'CA)
Signat
http://www.mass.gov/dep rovals/t5forms. htm#inspect
L, 7 cl
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key,
http://www.ma
t5form4 doc. 06/03
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHLJSE
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The S st
be submitted to the local Board of Health or other approving authorit
81„11„ 1 8 200
Rord m s
A. Facility Information
1. System Location:
.reti291
Address
City/Town
2. System Owner:
/1&)(49L,
Name
State
Zip Code
Address (if different from location)
City/Town
Telephone Number
B. Pumping Record
1.
Date of Pumping
2, Quantity Pumped:
Date
3. Type of system: El Cesspool(s)
Other (describe):
4. Effluent Tee Filter present? [I] Yes El—fici
5. Condition of System:
6. System Pumped By:
/2t,
Name
/LJO
Company
Gallons
Ev‘ptic Tank [1] Tight Tank
If yes, was it cleaned?
7. Location where contents were disposed:
4
water/approvals/t5forms. htm#inspect
Vehicle License Number
Date
LI Yes E-11-6
System Pumping Record Page 1 of 1
System Owner
Type:Em
Cass 0 0 0 I: No
Date of Pumping:2
Commonwealth of Massachusetss
Routine
Yes
System Pumped By: Wind River Environmental LLC
Contents transferred to:
Contents Disposed at:
Date:
Massachusetts
System Puinnin9 Record
System Location
4 -- Systemlumping-Reco
Septic tank:
QuantityPum
Permit #:
AUG 0 2 ?DU
A N DOVE Fi
Condition of 5ystem/Other Comments
Si
bep Approved Form - 12/07/95
Form 4 -- System Pumping Record
Owner
Type: Emergency
Cesspool: No
Date of Pumping:
Commonwealth of Massachusetss
Routine
Yes
System Pumped By: Wind River Environmental, LLC
Contents transferred to:
Massachusetts
System Pumping Record
System Location
Septic tank: No nYes
Quantity Pumped: /SOO Gallons
Permit #:
Contents Disposed at:
Dote: Pumper Signatu
Condition of System/Other Comments
1
bep Approved Form - 12/07/95
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: \_\0A
SYSTEM OWNER & ADDRESS
5k-t
DATE OF PUMPING:
SYSTEM LOCATION
(example: left front of house)
QUANTITY PUMPED 00 GALLONS
CESSPOOL: NO YES
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SEPTIC TANK: NO YES
SYSTEM PUMPED BY:
COMMENTS:
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
1-0.014-Cr,
CONTENTS TRANSFERRED TO
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: Yam` \ 1 \oD
SYSTEM OWNER & ADDRESS
+'O I
19 `\n��
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: _ 1) \ QUANTITY PUMPED 600 GALLONS
CESSPOOL: NO YES
SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE / EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM[ PUMPED BY:
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO:
Homeownc_
Stree
Phone
Nature of Service:
Observations:
Description: of Work:
Comments:
Phone
Routine
Emergency
TOWN
OF ANDpVER
SEPTIC SYSTEM SERVICING
REPORT
Pumper
Address; : L'l
Good Condition L�
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
other (Explain)