HomeMy WebLinkAboutSeptic Pumping Slip - 55 FARNUM STREET 7/30/2018 .,.
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Commonwealth of Massachusettsf... .........
City/Town of No Andover
° System Pumping Record a.
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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted tc
the local Board of Health or other approving authority wit to f4 f u° date in
accordance with 310 CMR 15.351. "
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A. Facility Information � �.I��m� �1 � �'���1
Important:When
filling out y Location: �� UMN('�u NC)R 1164 ANK)0val R
usthe e only formsb' 1. System L_ V Wt V�t V'"0 t P Gv p i r
y
key to move your Address - _._. _.._.
carssor-do not No Andover
use the return _ __s, Ma
key. City
[Town/Town State Vp .dWe __r
�� 2. System Owner: ....
r�S
Name -.--.
Address(if different from location) - 'T `---- -�
City/Town -
• State
Telephone Number
B. Pumping Record
1. Date of Pumping rate 2. Quantity Pumped: --
Gari s
3. Type of system: [1 Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe): - —
4. Effluent Tee f=ilter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. S s Pumped By;
Name Vehicle license umber
Stewart's Septic Service
Company
7. Location where contents were disposed:
Ste rt's re-treatme nt, 20 So. Mill Bradford, Ma 01835
_ _ t
aider Gate
Si tore of Receiving Facility rate
t5form4.doc-03/06
System Pumping Record-Page 1 of 1
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FOrrn 4 TOWN OF NOR
TH ANDOVER
� DEP has provided this form for use by local Boards of Wealth. T i � or must
be submitted to the local Board of Health or other approving authority,
A; Facility Information
am tting out 1. System Location, 'Z—S,
forms on tta l
Computer,U"
only the tab key Address Zip code
to move your
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use the rngam
key,_, 2, S stem Owner,
w ,..
game,
rArr I"' Address(If different wrvm tooaUon)
CltyCt'own
State Zip Code
Telephone Number
B, Pumping Record
1, Date of Pumping Date
2. Quantity Pumped" c Ilona
3, Type of system; ❑ cesspool($) 1 Septic Tank ❑ Tight Tank
❑ Other(describe).
It es,was it cleaned? E] Yes ❑ No
4. Effluent Tee Filter present? ❑ Yes ❑ No Y
5. Condition of System; ( }
�J
6, Sys m Pumped By,
� --- -- —
Vehicle License Number
me
+ry ,
7, Location re contents were disposed, m
Date
Wo or
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ha:provide t1(,1tform for use by lac I Board14'of Health. The System Pumping Record rrausi
be�submlttad to the local'Soard of Health r other approying authorl`
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Date Z. Qttanklty Pumped:
Gallons
iTYp9 of system, �❑ Cesspool(s) (_' ptic Tank ❑ Tight Tank
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° 4 eluent Tee F1lter pr8sent7 O Yes �o, If yes was It cleaned? ❑ Yes
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TOWN, OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
S STEM 0 NER & ADDRE,S,S
S'l .M
SYt'OCATION
(example: left frolit of house)
DATE OF PUMPING: 42;� -0/— QUANTITY PUMPED, ZeVO GALLONS
CESSPOOL: NO � YES---� SEPTIC TANK: NO. YES
NATUR-E OF SERVICE: ROUTINE_ -X2 , EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVE,R
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELDRUNBACK
-EXCESSIVE SOLIDS FLOODED ------
SOLIDS CARRYOVER 07'BER (EXPLAIN)
SYS'T'EM PUMPED BY-
-OMMENTS:
0-NTEN't'STRANSFERRED TO:
M4.'zg
d
lll4(4h AN16ver 2-6. 4--
ST WRT►s SEPTIC TANK SERVICE
)fib .Nla,n Sf 47 RATm= STREET
AlA fl h BRADFORD, MA, 01835
N u b
Lot-c. 15'l -ACSN 978-372-7471
1nLot
MOMMY REPaI r FOR TpWN OF 1V r o�f'
DATE ADzxREss
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