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HomeMy WebLinkAbout- Septic Pumping Slip - 59 WILLOW RIDGE ROAD 10/11/2018 TOWN OF NORTH ANT OV ,;R SYSTEM PUMPING RECOR—D I ,) STEM OWNER & ADDRESS SYSTEM LOCATION (mimple: left front of house) l>:j'c Of PUMPING: ��J ��%�`� (QUANTITY f UMPED ���=�-� G'ALG.O ,v C. 1:'S.SI'OOL; NO YES SEPTIC TANK: NO — YES NATURE Of SERVICE. ROUTINE IwERGENCY c�l3,SF'RV,;\T10NS; GOOD CONDITION FULL TO COVEIz HEAVY GREASE BAFFLES IN 111.,ACE: ROOTS — LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVE ft-1ER (EXPLAIN) �1"`7"I` 'M PUMPED B Y: l � ... � U�"1'I:'?�''I'S '1'I Z A N S F E I t IZ I✓D 'T'O� ._ __.____._. _____ 1 F } J � ) y1 t a � � r - _ f 1, P fn 1.Sir _ now + ,.x15 P r h t r , Y r nI`( ' d f �a^............ �� .; .. � 'I'()WN COW ORTH ANDOVER SYSTEM P JMI'IN0 RECORD Nov °� SYSTEM OWNER & ADDRESS g SYSTEM LCiCAT7t71+I`� lh�l I e�-A `61 4, DATE OF PLJMPINO: --....,...:,:. �� S51'OCUI : NC) YES SOPtic Tank: NO. YES' NA FURS OF SERVICE: ROUTINL,'y' I:MEROE;N(')' 013SERVATIONS: 0100D CONDITION PUU. TO COVER L HEAVY OREASE BAFFLES IN PLACE, ROOTS __...._. LEACHIMELD RUNBACK EXCESSIVE.SOLIDS FLOODED SOLID CARRYOVER...'. ,w_OTRER EXPLAIN `ayataarn I'umPcd 77 1 CUMMhN l',5. CUN 1'EN I.S 1'KANSyi1RU D I'0 r •, 1J 4 i �ir•,i�'•��,ut/�y�o �S«,e�r'trt}� k�h^q�'.rr•,',�!•: •; - . .. •' J �'t5t,�r fr(J.4S '�r��t 4'�y�r, w �� 5`� J4{��,f `N'4''•. iv *lV.Y;,�.1• t„•J� rl�yl l'1{{j�a�y , r1 ,Yt J Y'1 R4''�JJY+�I�Y'Y'`wr 4'r.f;,r;„,, 't•' �.`^^„ ' t'}r! •r,l• t A L+ l�t,'y,I J",},Y tit . w l i .w -. `aY Mr P JMPI14 Q Kp-c� ��W-'A 11ilcEP'Nr�rMENr TD A T� OF-PVM-N 0�7//' �`t�7PC�Jlt N YL5„ .,. , rM C?r 3RYIG`B; ({f7V'{N�c°" CrtirtKwt 000D CC�t;ID�r�`iVN YVLL I'V t �7Yrx Dr'•}'Y U IN 44T3,• .,r.,, l.fSe4CK7IV o KVNEt �t'r, WOMB �OlrlpB .r PL©4D�b XLtDC WS hY 01"NER•EXPLAIN „ ,4Y$AJ�4�,Yr �/Fey'�./y(//� �r^\{��7, M ,iti l�.b/�{A lr"�+r�1�/tea/,rj�/,, .ti•r�� 4 rr �I �ii 4��L f •�'���5! , YY •,Y..w ' r e . n,Yrwre ,ra w ,. e , ,,, .•. r commonwealth of Massachusetts .City/Town�af NORTH ANDOVER MASSACHUSETTS S .stem' Pum i t \j Y p ng Rec,©rd Form'4 DEP has provided this form for use by local Boards of Health T"_5ysLern Pu rl'p ng R cord mu: be submitted to the local Board of Health or other approving authority � l �� A. Facility information , Important: When filling out 1,� System Location: forms on the i� computer, use A. move a tab key Address tonly to move our cursor-do not Clk Dawn use the return y p key' 2. System Owner: Name Address(;r different from location) City/lawn State — Zip Cade Telephone Number— "----'___._._._._. - w , Pumping Record _.. 1, Date of Pumping Date2Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑"No If yes, was it cleaned? ❑ Yes ( do ... r 5. Condition of System: 6, Sy em Pumped By: 'Rama , Vehicle License Number Company 7; ,. Location where contents were disposed: Si atureofNau http://www,mass.gov/dep/water/ provals/t5 forms,htm#inspect t5form4.doc•06/0 System Pumping Record -Page 1 at t ►ii;�� j 'a v''ry"�� ` „r' '1•r' r 's+�9 a 7Chusets ! t 1 •;4'',r•P+M1. 1r.,wY �It.{1� X,f9 � f ... •. ,, J'J r,. 'y•r t .tr yt ORTH AJVE NIAAHUS `FT . �1!huilap�, ord ' a r+•'c:.1 ��"{ ir����•,�iw��t;rY�w jY�l"j�+�4�yYf �.a(tP I a'r) t INM has' rdWded thta form for use by p, Local oards of Health. The Sys em Pumping Record mast ::be suTbmiktedl1to the.local Board of Health or other approving authority, A, Fac111 ,1nfor'rftt1on ��:1rt,�,ortanC:. � Yr,t I.;:. . .• unq _ f , System 1. ,,;�Jr• f►i, the � S 3 oC,a�lon on • ;v`�"CofrYputBrt�USB�, jf only the tab key Address ...., L -- to move your /? oursor»do pot M Yi7 t'" u;js,�e'+bt`h�.e,Y4t y.lr y•oU�tr`tglu"fmt'y 1((,1 Jt wIft,;IiI%Li e,4sC1 f I•`to.wr nrI State �pV W,, s yst ®m wpe; 1 t , +r+ t Y t V/• Name Y r 'li if r' "r —__...__w_ �J " " 1 Address(If different from locatlon) • . —_.— Clty/TowC� State , , w , Telephone Number 'rk mp g � .�' U 1�1 Re{ cord ^)�•. I `• , F.�Yo�Ystutl.f t. Jrr(Ic rs�rf�Y11t'rl•7'� 1{ .a ti•" a Da*of Pumping ' 2, Quantlty Pumped: ' —_- Dale, Gallons :I Typ® pf system. ' ❑ Cesspools) aptic Tank ❑ Tight Tank �• ` 5•f Y. � '+ether(describe), .. r 1 ,f'r + yt, + tK{Yj+'j 5 J 1� •- 4,, E uen lea FIR r$sent? Yes o` If ffl k I p ❑ yes, was It cleaned? [] Yes F] No t 7 I yr,W1 Y f .• :..••r�.,�ft Si ��.11%�JS br r)1.aSril�� Suit+l l,,Ji;t+�: 'f'�Y.,71 t I.r, ... r:,. ` :',i:• r :.t +,��4k 1. Y + �. "m' ._....._ • `". '• t, is�� Y r 4�w'err-'}�^r.:1�ii, � <r 17yi f: i ,...... + a'�", ,1. ,t•'tfi t..Y.:1�1'S;:�'i:1,t1417 ti yl,ll�ltl'y '' ' , , Pumped By; ' j ' 45*4 F1( Il,a' ama1�`)••t 1plt l pt, !' ay i1'«+i•'H V JJU t,L♦r .,I � jV®lilcle Ucecen*fie Number \f ;, ll ; "#4,7w4°yr5I,!'r ,�`7J���/4��N'.M^y]�� 'SY S.Vd 4 .i�f'i,:JY,,:. ,.It` •1 V� /► ,y'i t Y!�'�' �h r�rrhr�,k>,�"�f,S1�' l'•� ti+X ^li�4k� ''�' y`• i ,rr y .tl S' y 1 'yS�r ` rFt bf of%N Yr}.i }ri M 5I1•UilkyttY,. J ylr�3l�/�ryt•'0, 1 ✓ •`y r o !+! (! r t +•k t'n 4H?li�fr 77t+�W o' I' 7 �Y �'t •"'r '• " M'6h'vrhere cpntents yvere`dl posed; Ll . • � . r {. \ ,Jt'./I 1 ``N�pr�1{1 I•I/•1 {"{!C r., '.•54r �Z11 UJ r,t.l„F. SWnatUta of Hauler• t+/„}s!'S ', '1' Date http://tivivw,mass,gov/dap water/approvajsltSfarms,htm#Inspect 00 t5forrt>4 docr 06JQ3. ,•• System Pum Inq Record Pa ge 1 of t + !?•,I, r{�Y fr "','.a a .r;.,iiaj ars5'3,,'Pr (fa +'�' , k.2f ;j I lr - fit'' y + � t 1 �(nj}p(' �f qL/Sy,P;'!,w•, �'�l'Iilry�lJ(1ry`r'f J,,•1 C' I J r !� •') J '�iY 11 Y YIV \ l► 1��� ! i m.w.�.. 66���'1�,11 wl''I /dl V:I N •,I Mi'".�eP,f1��wJ`t ICt l'9 y'4"�!�•V�'I'�C�`r•!, �.� ' „ V�J Q PlgYldrd JhJr fgrrrl !pr t r 8var Ivo(I)III90 �v ° ��' rvcor ' v! ^uf ' Y .o s v�r Ivcrl6vr,l; c''! n �1 •••',•,� PUlln pr Clltpr , q (/ 1;a.'71 A. Facllfty Inlprrrlllari "`"" '".��;��•', ,,,� ����vr�J PAN �I�) "' rtN r�RTH NDOVER RwA(IQ ;. .., Ram IJ. " • 1. ��'i r�`I YI 19 1 r i h,'r'r`'', t t'J,��i�`no I','; I rl,��.;,,�,�,, t �I r I""'I�—�.•�_.,.,,,,�..,,,, _. -,..... •rl•�,i�l+�'s,,<'r� �I�'„g' �14 m 01ti'i1', v iral tLi'i Ills r • �. I,,,' V� r'i;tJt`1�J�7�', ImJ t•a �"7 I�r'�f��`11''f'"''''•"' �� ,,�' 4 .. �(,...� .�� ""'"' V ° ,irl',, �I�r t",1 Y't'ir'I��.1 u',I,�,14'•e 11�•, _ �--`_ ''�:'"`r'•4drw+ 4 Irini ta%n buVvn) i 1 i;17ngni 17101, — — �L + IDS'�Y`11'I't«i'v14VNuPII�ITIr's I "r�•'' 1t Oslo of Pvmptnp ', ,•. r�Ql^�4�� 1y��Om�., c91r�001(,) (� 0 lic r r:.. ' ..�IV•f Pr"r',i'�'''4`III"�'�S' IVY741�11,1r�/ ir','•• .,.. Ir Yell 4f,1t/lI,i1Jl� ll wr„Sj,l'ry/It,ti;i/jE, •I '.,l',,',J,f!•ii lrrYr SI a '�r li�' �,I � 'I' • � ,a�Q`,„4i r lr'IIVII'Ir ;'�i�r,It�,ylr't�l' , . . Pv 10, � +,"��,,�P _I,'�r►"Y � '!rl l� '� r'�V'S I '�'I I���n.....ti., I {/ • , . t�'i.l�/h'l��'�!��Vv r `, �f��rr�rVr��4• II' ' , I'�''�j 7 1�r Ir / ` / r ���.��',„�, (vV�J"'','`/t��Myll1� (�'�I`i11rkM,Jll �'S����1,41'�`fE�«�ljtf'•' ' �� Odd Pnlr�or! aa�f4nc�' I Qr9 ,�, 10g439Q; ' ' •. +i,/I, „ .Ire J'y.� ''ti i'r r, ,'I" rl; r.e• /YYYltttfflV//li}/ // / 9/N1YG(�+�tyJ,,l,,',.,,II , .1116 sj ��Yld 0 ''' A' a11APp�4YiJsldHQo M),n;'nfI•nI�bsl Commonwealth `����D������A���/u � +// (�'fu/� mf ��North Andover �� ��/� �^' "n�j/ u , /��w�3v��r �� �' ^ �� Pumping Record �������� x �������� u�����u � Form 4 OEP has provided this form for use by local Boards of Health, Other forms may be used, but the information must be substantially the same ao 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 nr other approving authority within 14 days from the pumping date in accordance with 31UCW1R 15351 A. Facility Information Important: When filling out 1 System Location: forms on the computer, use 59 willow ridge Rd ------- t-Rz AL]H EX]:PAP(Mr­ T ir only the tab key Address 0o move your North Andover K8o —01-845 cursor-n' do not — cxynnwn State Zip Code use the ngum key. 2. System Owner: Robinson ����� Nome Address(if different from location) d*yT*wn Siotm aipCodn B. Pumping Record 5/2O/11 1000 1. Date of Pumping Dme 2. Quantity pumped: Gallons 3. Type ofsystem: El Cesspool(s) N Septic Tank E] Tight Tank El Grease Trap [] Other(describe): 4. Effluent Tee Filter present? Fl Yes No |f yes, was itcleaned? El Yee Fl No 5. Condition ofSystem: xoo|ids O. System Pumped By: Frank E|d id Name Vehicle License Number Sha rt'e SeiDtic Service Cumpany 7. Location where contents were disposed: Stovvort'm Pre-treatment Plant, 20 Go Wli|| Bradford KXe 01835 Signature of Hau r Date u�neme nY��mrvinO Fmci|ity oum Commonwealth of Massachusetts " City/Town of North Andover - SystemPumpingRecord Y 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 forms 1. System Location: an the computer,use only the tab � � ❑��� l..h., ' -- key to move your Address (� cursor-do not North Andover Ma 01845 use the return -- — -.. . key. City/Town State Zip Code 2. System Owner.:_Po ran --- -- ------.......... Name ervn Address(if different from location) _ -------- City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date _,r 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) (�i 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: ---- 6. System Pumped By: Name �.- �""1/` _ �4 J4... .1 . " - _.__ Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: ---�St -- tment-PJaot,.20 So. Mill Bradford, Ma 01835 i r s"pr�-trea_ ❑ .. . _. _....... Sign ure of Hauler Date Sa na ure of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts pPjj (V;E VED x City/Town of No Andover System Pumping Record ��� Farm 4 lay E ���rpjgi �'� I I Vri9,itl f ,p,"4 i DEP has provided this form for use by local Boards of Health. Other fon 3" r ay'be 6s' 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 C''MR 15.351. A. Facility Information Important:When filling out forms 1, System Location: on the computer, use only the tab 59 Willow ride Rd_. . . -- key to move your Address cursor-do not No Andover MA use the return __. _.. key. City/Town State Zip Code 2. System Owner: Robonson Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 2. Quantity Pumped: L 1. Date of Pumping date . ��— Y P Gallon 3. Type of system: ❑ Cesspool(s) ' eptic Tank Fj Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ` --o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number. Stewart's SeVic Service Company 7. Location where contents were disposed: Stewar' Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835_— r 4— Si at a of H ul „� ,� ateSii .... . . ataiqu date t5form4.doc-03/06 System Pumping Record•Page 1 of 1 I