HomeMy WebLinkAboutMiscellaneous - 49 OXBOW CIRCLE 4/30/2018 (2) 1 49 OXBOW CIRCLE _ft `
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Commonwealth of Massachusetts bra
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
yr Form 4
M
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
Important:
When filling out 1. System Location:
forms the
computer, use
only the tab key Address
to move your
cursor-do not City/Town
use the return State Zip Code
key.
2. System Owner:
Name --
Address(if �{
RECS" _j
City/Town State Zip Code
MAY 11 2006 TelephoneNumber
TOWN OF NORTH ANDOVER
HEALTH DEPART'AL:vT
B. Pumping Record L�
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) s32ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes.R124;ir If yes, was it cleaned? ❑ Yes
5. Condition of System:
6. Sys' m Pumped By:
am�� � License Number
Company
7. Location where contents were dis osed:
Sigr4ture of Haul Date
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 of No. Andover
a 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 Pumping Record must be submitted to j
the local Board of Health or other approving authority within 14 days from thrwgQq
accordance with 310 CMR 15.351.
A. Facility Information JUN _i CU11
Important:
When filling out 1. System Location: TOWN OF NORTH ANDOVER
forms on the HEALTH DEPARTMENT
computer,use 49 Oxbow Cir
only the tab key Address
to move your No. Andover Ma 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Morrill
Name
ICI Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 5/31/11 2. Quantity Pumped: 1500
Date Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Good Condition
6. System Pumped By:
Chad Tannian
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
v4prt's Pre-tre4tfPeQt Plant, 20 So. Mill Bradford, Ma 01835
n ure o er Dat
�
'3) /
Signatuof R eivi g Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
/v• %nc�o vP�
DATE OF PUMPING: QUANTITY PUMPED GALLONS
F
CESSPOOL: NO "ES 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: c)ov e-1
l
COMMENTS:
CONTENTS TRANSFERRED TO: �
/Yp�U U die '-'AY -4 200,