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HomeMy WebLinkAboutSeptic Pumping Slip - 410 SUMMER STREET 1/8/2018 FZ Ufa I,"V E , Commonwealth of Massachusetts AU GQ 0 3 City/Town of Norq-� �' ���� System Pumping Record � �� c=' F' ��� ��° 1 Facility Information: System Location: ry Aditress C City/Town State Zip Code System Owner: voi/ Name: Adress(if different from location of pump) City/Town State Zip Code j Telephone Number Pumping Record Date of Pumping ,,.S '9 /5 Quantity Pumped 0 C _ gallons Type of System Septic Tank Grease Trap Other (what) System Pumped by: Company: ROOTER-MAN 46 Portland Street Lawrence,MA 01843 Location where contents were disposed: Signature of Hauler0AVIIDate 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 Pumpin vst be submitted to the local Board of Health or other approving authority within 14 days from t e pu accordance with 310 CMR 15,351. A. Facility Information Important: TOWN OF NORTH ANDOvept When filling out 1. System Location:,f--,, C:z P1 LTH DRIPARNOWT forms on the computer,use4 ❑U__' - only the tab key -Address to move your No.AndoverMa 01845 cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Name relwn Address if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping2uantity Pumped: _&a_te_ . QG'�i'o n s 3. Type of system: El Cesspool(s) Septic Tank [:1 Tight Tank F-1 Grease Trap F1 Other(describe): _..._a.......__- 4. Effluent Tee Filter present? Ej Ye No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pu, Name nse Number ' e Stewart's U'e rtic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Ha I r Date r Signature of Rece Facilit Date t5form4.doc-03/06 System Pumping Record-Page 1 of 1 .,`4ni y, ( rioviyassacusEr-rs �rE3CQC ,ry1bR��tr •' Or " " %'f,'�, ,El'�° '4ty'ak," 'r `•ir'r,•r,' - - �RECEIVED ! �';i." t'.ttipl(.e.';:'t�..",�'•''DEP,,ha� prav(ded thfi form for u80' by local Boar `r he tem utnping Record rr,� ; be subrrml4e'd to the,l0ca!'Board of Health or otheuthority, 'iTh��"ae�D�"��P�"�� I A; Facility.lnf©rmati0n . �J,,YYhen'filling out .1 r System Location; .�,r�,///` t]r��+,/ � wYi►. UtBrva t,r /.L ✓L�✓/" ,�, ?A / 7 0,*the W key Address y _ to move your r cY% "� r �k�,✓�2u!'���W /� �p ' .easter,da,frQt '"r ` {tisi the rotum Clh�TQWn Stale ..;: ZPp Code System owner,, r , r , t it A,`'`•u /. 1 1 r`' Name , F `r' � j r1y';!fir - } .i' i.r��,..1t r .' 1. �*—•T,.,' AddiM(If different from locativn City/Tawn a. „ r: Stale' ;�j Telephone Number •irr � • �t i r +r':a X11 ,'Y'��J! 1^I.�t.p".�,�•.!r►V.T V)40 ''.a. •yJ,, , yl IdtM'f�y ll�ri"rrr r +robs.,ip�,.l�Q'{ri?�tr f l�, /� patq of Pumping Dato 2, Quantity Pumped; G Ions TYpe pf,system, (�" cesspool(s) S ptic Tank ❑ Tight Tank } C FOther(aescrlbe), ' 4 Effluent Tee F'lltef presen t? .,Q Y °- If Yes, was It cleaned? Q Yes ❑ No h ( r(� Capol to o('9 t rri;'' r' .,. VVY • '.'.is r :'.r ,w,t,t{ ! 1 +� � r—� - '•". - '.r.�.t',�",^!� Yf. .lir +/ `?"'��1.:r�ri,• ir1lrlx" xr' ,.,_-. ..... _-__ r ori.yir."t"4•a.{.U:•�(�{i7.(r<ti".lt • 'Y Y Pumped 6y; " .,,' 1, u : .t, al. l> ,, 1, ,,.1.•,5,`,�� �./ can eNumbar 1'��t i 4 t' rt ���j;'r n(•M i'(f��"{t�, .4i ;�`���,y t ' /,/ry/y(//'� '��°� !�`1Y'r �1rti l Y'J'rM��)�J�f,rtr' f•VI„! t(�� ''�{,111L ;fr , '�: �� r • 4""1 j!!yy�y+tyr >y1 > h t rf ' Ir 56� 4frt r '.'�:. � r ✓ r r. w.,i 7r t V,;°' ,y"�*11' , Hrii•1 �.,+.,.;•, y i�' W�; .;�, •, a,7 . L'ocaflor►where contents,were`dlpposed; a 0 ••.i;.,../a•,r ai(:y�' •„ f ­00 '�i�• , , i Jr •�tt , .1 ti 1 r 4 / ,. • iii / r ,°ri t.{� ,��,(,•,1�. 1 t ti , t ,rr a.r"' rr 1 +�r�rJ i�11, ♦� 1r li} Irk ra f,r. ',., ,r �'Gr�'i 'r'd rt , •,51. .''� ` �r �'i,�rf'.JL'r:�,''"�fP.rr1 tW� ht#�i:Jh'w�v.mass,VONephwate'�approve}sJt5fam�s,htm#Inspect { ,Vr t5fOrrn4 dOtr 061Q3 System Pumping Record "Page i of 1 gv.1y�rti a1r �Sy' WAy ;y Jar lrl�r�x 11�tiy,�Y , ������y�j� ��;�� � r��{�! t,` �; "�..�� , 'tV1"SYtZFrK/ `�,�" Y� missal " �j;�"��'8'•I,1•,•" W t r ,m �akX'; �$� m �:�'"C� �° ' I / y y w ra �, 1 1""�L;a+www'..•.y er d r r 1 , gym tl C,9 ' .. r TOWN a� J hit f I N V RJ!( O yc t.. N ; *7,-)-V7 _ 1 Vaal Wa�V ba+ IJJI bb au., • ,4vauti, ao1� �{yytt 't.In9°/rv".� 3 »rFw yo VVGA.. i�) co rx C �KJ5�'c �,a.�l�, �� EXPLAIN 7�I 4f rn . w r �°"_�r�r�]f V.(%,1 f„r/v/i/��.,r .�wek:Ww� �l�p+'.t��.�r('�' w�•//t IM(: I , (y"f �I�r ,f r 4w+I'!� �� I".(`;r+`�}•.�/.•� r ^y.,, a TOWN OF NORTH ANDOVER SYSTEM PUMP1,NG R-ECOR- ,1'S'FEM OWNER & ADDRESS SYSTEM LOCATION (extimple: left front of house) 1).\TF OF PUMPING: (QUANTITY PUMPED &V/ 'ALIO)'`, C'I:SSPO0L: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE �'" EMERGENCY c) f3 �CIZV.=\TIONS: GOOD CONDITION FULL TO COVEN HEAVY GREASE BAFFLE'S IN PLACE -- ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED _ SOLIDS CARRYOVER tHE'R (EXPLAIN) ^,j P U M I'E D EI Y: l�'7���u'i' �r'wY7 -- I uu G f UN"I'F.NT' TItANSFEIZRED TO: