HomeMy WebLinkAboutSeptic Pumping Slip - 21 CLARK STREET 11/9/2017 .C-\ Commonwealth of Massachusetts
10 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
Important:
When filling out I System Location:
forms on the
computer,use 4
_ , .. ....
only the tab key Address
�ia C/)
to move your 1'e
cursor-do not stale Zip code
use the return City/Town , U b
key. 2. System Owner:
ame xv"
Address_(i_(_d_ifferent from location)
b_ Ao. 21P Code
'6tyffown State
Telephone Number
B. Pumping Record
1. Date of Pumping '6�t.e 2. Quantity Pumped:
Gallons
3. Type of system. Cesspool(s) FrIseptic Tank El Tight Tank Ej Grease Trap
Other(describe)-.
4. Effluent Tee Filter present? 0 Yes rA_> if yes, was it cleaned? ❑ Yes M-n-0,
5. Condition of System:
6. System Pumped By:
Veh5cle License Number
Company
tumberCompany G.L.S.D.
7. Location where contents were disposed: North,Andover, MA.
S'v;nea1Ute--_A- a'ier Date
-Signature-"of—Receiving,-Facility—,- Date
l5foan4.doc-03/06 System Pumping Record-Page i of 1
' •....
a used,but the
forms
p has Provided this form for use by local Boards of Health, efo a using th s form,check with your
CE
information must be substantially the some a8 that providedRecord must be submitted to
Local Board of Health to determine the form
taulhogity w thin e,The 14 days f astem mnthe pumping date In
the local Board of Health or other.approving
accordance with 310 CMR 15,351. -�
A. Facility information
important, 1. System Loc ton:
When filling out
forms on the00 �,, r�
compulur,.use Address
only The tab keyO`i Zip Code
fo move your pr irti stale
cu+'sor-do Rol Crfy�own
use Ine relurn
key. 2. Syslern Owner,
Name _..
tom' ,4ddress(if different from locaiianj. .. -- - _. — .
_ _ _• -- - Stale ZIP Cada
Cllyfrown
Telephone Nun'ber —
B. Pumping Record
2. Quantity Pumped'. Gallons
1, Date of pumping Date
3. Type of system: ❑ Cesspool($) {�
Septic Tank � Tight Tank ❑ Grease Trap
�] Outer jdescribe) "' -
Yes No If yes, was it cleaned? [❑ Yes .�No
4; Effluent Tee l=ifter present?
[� �
5. Condition Of System.
6. System humped By,
V hiCle t lcinse IVui7Yt}er
Name ^� l
VIr04t�1 'i.i4V(y -
Cbrrtpa-ny
7, Location where contents were disposed:
- Gr.L.S.D.
Ne"* ATIAOVer.MtA
8fg_rra17ure of Hauler
__ - - - - pate
Signature of Jieeelving Facility
System pump+ng Recotd•Page 1 of
15fnrrn4.dac•U3ldti
i
�L\ 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 sijbirnitled to
authority within 14 days from the pumping date In
the local Board of Health or other approving
accordance with 310 CMR 16.351.
A. Facility information
Important: System tocation�
When fillIng out 1.
forms on toe
computer,use . . ........ ER
HEM'141 T
only Me tab MY Addregs
to move your
--,�- A State Zip Code
cursor-do 001 Cdyffown
use tt)e return
key. 2 System Owner
V"-
N
Address{if afent from
State Zip Code
Telephone Numiler
B. Pumping Record
2 Quantity Pumped'. ?
1 Date of Pumping Date Gallons
3 Type of system 0 Cesspool(s) 6-aeplx Tank Tight Tank ❑ Grease Trap
Other(describe),
4 Effluent Tee Filter present? r] Yes L] No If yes, was it cleaned? L] Yes L] No
5, Condition of Systerrl:
6. System Pumped By, AIA
NaMVehicle License Number
m
company
7. Location where contents were disposed:
GI.S.D.
signature oI Hauler
Sipnelu�C-o(ReGetving Facility Dale
System Purnping Retold-Page 1 of 1
16form4,doc-03106
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
❑❑❑r Form 4
DEP has provided this form for use by local Boards of Healtl '—. i ng R
cord must
rteol I
be submitted to the local Board of Health or other approving a th n y.
A. Facility Information TUG
Important: � VVN OF t4C)lTl-i ANDOVEER
When filling out 1. System Location: HEAL TH LAIT-1AR'rMENI"
forms on the
computer,use
only the tab key AddrSS
to move your 4 � �❑ -� _ ���w
iL'
cursor-do not City[TowiT State Zip Code
use the return
key,
Z System Owner:
Skr+ Ctllclk-'/
Name
ercaa Address different from location)
City/Town State Zip Code
-C
Telephone Number
B. Pumping Record
I
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) ❑—Septic Tank Ej Tight Tank
n Other (describe): ------
4. Effluent Tee Filter present? El Yes 2"oto If yes, was it cleaned? D Yes El No
5. Condition of System:
6, System Pumped By:
Nar e Vehicle License Number
Company
7. Location where contents were disposed: 1pswictl Water
NIA 01938
Sig nature of ilauler Date
f)ttp://www.mass,gov/dep/water/approvals/t5forms,htm#inspect
15form4.doc- 06103 System Pumping Record- Page 1 of 1
Commonwealth of Massachusetts
mm City/Town of NORTH AND.,O,VERL MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of HealthT4s6j,$�"-j4`ffi g-R, cord must
be submitted to the local Board of Health or other approving Ethor'A
y.
A. Facility Information
Important: TUMJ
When filling out 1. System Locatic
n: I i LEPA
forms on the V,
computer, use X
only the tab key Address
to move your
cursor-do not J NA ci
use the return City/Town State Zip Code
key.
2. System Owner:
c'
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
I, Date of Pumping2. Quantity Pumped:
Date Gallons
3. Type of system: F1 Cesspool(s) EYSeptic Tank F-1 Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? E] Yes 9"No
5. Condition of System:
6. System Pumped By:
Name Whi&le License Number
Company
7. Location where contents were disposed:
D
Signature of H Date
http://www.mass.gov/dep/watert�prroval 5forms.htm#1inspect
t5form4.doc- 06103 System Pumping Record-Page 1 of 1
Form 4 __ System Pumping Record of iyiassachusetss���" "'".
Massachusetts � V��
� i Re
SAY Abe
I
System Owner s�m Location
-7777=�.� _w...,_..._..,
t
f/
t
Type: Emergency Routine
Cesspool: W4
Yes septic took: /PJ�a Yes
ff::j
Date of Pumping: Quantity Pumped:4 Gallons
System Pumped By: bind Rim,Environmental GLC Permit
f
Contents transferred to:
East Fitchburg
i
� � I
MA.
Contents Disposed ot:
I
i
Date: Pumper Signature:
Condition of System/Other Comments
j
1
I
bep ,Approved Form - 12/07/95
Form 4 -- System Pumping Record
Commonwealth of iMossochusetss
„~
Massachusetts RECEIVED
04
IV
9 2004
UL
All ,
�d' TO7REE
RTH ANDOVER.LT
PARTMENT
System Owner � � System Location
f�
1� �f
{oJ J,
T Emergerrcy Routine
Cesspool: w Yes Septic tank: w 0yes In
Date of Pumping: ��t_�` Quantity Pumped: Gallons
System Pumped By: Wind Pimp&vimnar ntal UC Permit
Contents transferred to:
Contents Disposed at:
le
Date: / ttttVeV4Jee✓ Pumper Signature: ///
Comciltion of Sy mer Comments
bep Approved Farm - 12/07/95
rr
Form 4 System Pumping RecovA
Comm"ealth of Mossachusetss
: Massachusetts
5"tem PWWM Record
Sysftm Owner System Location
-y'
�0
J,
i
Type: C-Menpmy omitne
Com pool No yars ptic tank. w [:]Y"
Date of Pumping: 63 (;�jant" PumLL
ped: Gallons
A I –
System Pomped By: Wind Mw 1--avironmenfal, UC Permit
Contents transferred tw
..................
qq
..........
A
Ir
Contents Disposed at.
Date* S—Ig"ture:
CORKIMOn Of SyStOM/OtheW COWCOU
bep, Approved Form - 12/07/95
Form 4 System Pumpir„ paUXHIA
CamsaaaaareaaltFa of aaaasaVaaaartssb
Massachusetts
saahusetts
1
System a* yas'Fe1a91 La"FIOWN
t'r � i; ,,rd 5, ( ?1��r � e."f 1 �., "��. 0�1"�(, �i 6 �� 1• w,ba„ �
R
�pag;f,}p „a,OA„v'
' gals Cir r✓� Yes Septic ta <s
baa Pumpi �w� �� � urantitye M wn�: : &Gaallara
System hil"PW By, wMd River 1."flVilaa^aWntaa, UC Per�swa(A
Carats Raaf to:
Contwits b1 pa aai at:.
bate. Pumper,Signature:
CwwliFlaara of yrsaaaFC Cher Cwnwnts
sip Approved Farrar _ 12/07/95
Form 4 -- System pumping Record
Commonwealth of Mossachusetss
Massachusetts
s
system System Location
1"ype. Emergency Routine
[,,�
Cesspool, w Yes Septic tank: pilo OY.. E
Dais of pumping; 3 -7 Quantity pumped: Gallons
System pumped By: Wind River Eaviroftinental, LLC Permit#:
Contents transferred to:
Contents Disposed at:
pumper Signature: ,O?'V .
Condition of System/Other Comments
bep Approved Form - 12/07/95
corm 4 -- System Pumping Record
Compo alth of Mnssacimsetss
Awssaciausetts
AMt%qi qtl rgrd
system Owner System Location ,i
,.
1"ypeamergenTh—
Routine
Cesspool: i 7 Yes septic tank: I Yes
Date of Pumpingq-.G� 7 Quantity Pumped: 6 Gallons
System Pumped y: WWI "lu x-Environmental, L.L6 permit
Contents transfer to:
Coa nts Disposed ot:
1
i
mate: t(- --p Pumper Signature: „® o, W
Condition of System/ thrx Comments
i
I
Dep Farm - 12/07"/9'
FORM 4 - SYSTEM PUMPING RECORD
CURRIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, NIA 01949
(978) 774-2772
COMMONWEALTH OF MASSAC11USETTS
_, MASSACHUSETTS
SYSTEM PUMPING ]?ECORD
SYSTEM OWNER: '�Vq SYSTEM LOCATION:
rz '
V__
C-) 1 :3
DATE OF PUMPING: GALLONS
QUANTITY PUMPED:......
CESSPOOL: NO YES 0 SEPTIC TANK: NO YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS 'TRANSFERRED TO:
DATE:-- ------------------- INSPECTOR: X7
FORM 4-.SYSTEM PUMPING RECORD
CURRIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET;MIDDLETON,MA 01949
(978) 774-2772
OMMONWEA II OF MASSACHUSETTS
MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNER: SYSTEM LOCATION:
t
Qa
.S' S��UQ GALLONS
QUANTITY PUMPED:
DATE OF PUMPING:, �
CESSPOOL: NOEr YES SEPTIC TANK: NO YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
}
CONTENTS TRANSFERRED TO: _
i
DATE: 'mac INSPECTOR: _
FORM 4-SYSTEM PUMPING RECORD
cu
"�*44�,
r�
M DD 1949
2772
/
„
COMMONW ALTH OF MASSACHUSETTS
t ;r ,=, "/e"� ,MASSACHUSETTS
" YSMMP'
�'1�2'FING RE (T.ZZD
�
"�"'��i�
T
J
SYSTEM LOCATION: w
K-v
t
G��N,
/
PIING: 3- QUANTITY PUMPED: /Soo GALLONS
/
' NO 'ES SEPTIC TANK: NO YES � —
,rf
l
QED BY,° R S 1'TIC & DRAIN SERVICE
��� CNTS.TRANSFERRED TO: Cr
d 1 Y
INSPECTOR: C7
G // „�
(� �j FORM 4-SYSTEM PUMPING RECORD
CRRIUi_1
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON,MA 01949
(978)774-2772
i
COMMONW ALTRI OF MASSACHUSETTS
,MASSACHUSETTS
S YS TEM P UMPING RECORD
SYSTEM OWN It: SYSTEM LOCATION: f
._
�vt ce-
bur% /4 4(:n 6j-adC
o1
DATE OF PUMPING: 3 QUANTITY PUMPED: / 1
GALLONS
CESSPOOL: NO a YES F7 SEPTIC TANK: NO YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE: 3 //c '/ INSPECT R: C a'
107 Forest St. p�N FORM 4 - SYSTEM Pt111PNG RECORD
rii.�c9
o8) 774-2772
5
Commonwealth of Massachusetts
..�`� .�..., Massachusetts
AN
Record
Pum ing Re-
stern ti�ner ystem Location
Krv!,y i33
301 3 •ryppyrvry-
0
Date of Pumping: 7— )-7
P €' Quantity Pumped; 4( allons
Cesspool: 1\o ❑ Yes' ❑ Septic Tank; No ❑
Yes IND Ao"o
System Pumped by:
Contents transferred to; License
Date
Inspectors
`'
THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY�
107 Forest St. P � C� r tr
RM a - SYSTEM PUN
MIddteton,MA 01949 �� x
.(508)774-2772 ;.
fi
Commonwealth of Massachusetts
IIaSChUettS
'ir x a
ec®r°d'
}stem UNNmer ystem Location
/ �roco ,
Date of Pumping: Quantity�
- Q 5 Pum ed:
p --------gallons
I
Cesspool:` No Yes ❑ Septic Tank: No ❑ yes -,
n�
System Pumped �y:
License #: ::
Contents transferred to:
t t frr
�,�
r
Date Inspector
q
tl
Nk
h;� si kyr t,R4� d ti
fir.. ... , x!b rklkYl yut irdq ,
+g,
t rl
X
! : r THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0
t
, r,��k4�Y� �IF�r�u,4Yai1,t°•�k�`
107 Forest st, hFORM 4- SYST'FAI PUATPING RECORD
�-,�ddl ton6�RF.MA 01949 5� � ���� �rC NORTH, ; €10 1,IFFM'
ca,
Con=onwe4th of Massachusetts
h�1nlCUQ r Massachusetts.
ostein umpLae Rena
Own r ystem Eocation
Date of Pumping: Quantity Pumped.. ; gallons
Cesspool: No ❑ Yes ❑ Septic Tank: No ® Yes
System Pumped bv: Lr-Y.-A..e r'` �C`. License #
. ......................................... ..................
Contents transferred to:
Date Inspector
Y
�i
I
107 �Oresrsi, bOFORM 4- SYSTEM PX.iMPL IG RECORD
Hidtktm MA 01949
5
Commonwealth of Massachusetts GIL
Massachusetts G "
p
1,
System Pump .,Record
System a ystem Eocation
Y41C160
Date of Pumping: ` Quantity Pumped:
gallons
Cesspool: No � Yes ❑ Septic Tank: No ❑ Yes
System Pumped by: I C License #:
Contents transferred to:
Date � � Inspector
107 Forest st. FORM 4- SYSTEM PUMPING RECORD
f,liddlelon,MA.01949 5� ,1\0
�Q�4�,�G
.-Commonwealth of Massachusetts
Massachusetts
System Pumning,�.Record
/6-
ysten System Eocation
,
/'
r
Fl�)f
-7Z) -:_I
Date of Pumping: / Quantity Pumped: I gallons
Cesspool:
Cesspool: Na p' Yes ❑ Septic Tank: No ❑ Yes,,—
D--System Pumped by: ............. .. ............. ................................... License #: .,.............,,.............,...,..,...,...,.......,.......,...
Contents transferred to;
Date Inspector
107 Forest St.
Middleton,MA otsas FORNI 4- SYSTEM PUNIPM RECORD
Commonwealth of Massach�
Massachusetts
System himping Record
System Owner ystem Eocation
/ _rld c FIX k
Date of Pumping: r� Quantity Pumped:..Z,2 allons
Cesspool: 'No Yes Septic Tank: No Q Yes
System Pumped by: License #:
Contents transferred to:
Date Inspector
A.