HomeMy WebLinkAbout- Septic Pumping Slip - 7 CARLTON LANE 10/12/2018 FOR NI 4 - SYSTEM PLAJ[PrtiG RECORD
Towtg IN
MOM R/
LPI
Commonwealth of Massachusetts
Massachusetts
System Pu=Lng Record
—SN,stem Owner System ocation
A C,
q&� d� ' Qw-
0
Quantity Pumped: gallons
Date of Pumping: All�_--e-1)
Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes
f-
System Pumped by- - License #:
Contents transferred to: L 0 -
Date Inspector
I*t',1 �7�
�`r :�
l
r r 1 ,1 I V✓P4 `,./,1' 11 `'✓".R 1 H D O Y E R,
, I I k Jt n,r Jt Y 1 V t I 11 ("'ti.141 '.
1 I
Co
PS-
5'1'EM UwN R & ADD CSS
,. SYSTEM LO
►im p le; left Iron
PUMi?li �;lUaNTITYhurnPCDll'�%� �` '
NO
1 ,i.sr dltl r'CI�)�rr )) ,ot5)llt o S , w
-
kYS TANK:
, I
�TURE Of S'EftY�C I'. R0UTINE. EMERM CY
.r
h'VLL"TO CoYCi�.
FI ', 'YRGf� r'rt`S'C' ' ' (3XlL11S IN C'l,aCd' _-
RL a C F r la L a �t ON u c
CXCSSIY .0L1[75. ` "(;C?C7.DE0'
50t1 CU CryRttiY4V �✓'�Q y
P� R 1 P
R `E!1 1 I" ki!1
r ) w�'Su >k�r�'1�)yi)+t)�+�sk'hC I ,(14Y�1e"1f rs r! :•,v r ,F Ird '� ��I
41,T�,b
M -
,
J
1 o Y.0
.I
1 l:a
r ` /tY�.r d4 iE ut �1�+1,dote I'.Ir,7f eriJ�'�ii 5 'r�'t
t,1
ft�tr .{t�) rr� t
t rj r111 'Y l,o,Ii.lru;-r �t
. r f (l�r,l���yX itt, "p r t d�rSrt,lsdu f 4 r �,
,
Commonwealth of Massachusetts
Crty/T"own
�
,of NoR°rH A[vDovER i�As , rT , .
Systern Pumping Record
.Form 4 , f)
DEP has provided this form for use by local Boards of Health, The
i nt yjterp,;Pgrlgpin 'f ord mu;
pp =�uic���l
e submitted to the focal Board of Health or other approving a t . ..
A. Facility Information _
Important:
When filling out 1• System Location: �
forms on the .
computer, use ___.1
only the tab key Address
to move your ZZI-2 1. G_1�'�Ci�2 _ C l _
cursor•do not l
y Ct /YawnT"" ----
use the return State Zip Coda
key` 2• System Owner: /
Name _w
Address((f dlNerent from locakion)
C___ltyfr(f _
awn_.
State ._. Zip Cade
Telephone Number
B. Pumping Record
W.
1• Date of Pumping -
P 9 ' Data 2• Quantity Pumped: Gallons
3 Type of system: ❑ Cesspool($) (9"eptic Tank ❑ Tight Tank
❑ Other (describe): _.,_ _.___......-----.�__,
4, Effluent Tee Filter present? ❑ Yes B�No If yes, was it cleaned? ❑ Yes ❑ No
5• Condition of System:
Xy e6d
6. Sy em Pumped By:
ame Vehicle License Number
Company t'A�
7. Location where contents were disposed:
$I atureofHau Data _--___..----•_,____-______. ..._.
http://www•masg;gov/dep/water/ provals/t5forms•htm#inspect
t5form4.doc-06/03 System Pumping Record• Page i of ,
��
ryl�
r Y
;, y jf}T}. `Y��:,�yaliyr�l � h a[ f'
�f1 on3'o?!'8,^�71�"�}',�T�Y7�Gic�Msetts
. yl own QovER, nnAssACHusE-rTs
PUmpirtg.Record.
Form 4 w
DEP has provided this form for use by local Boards of Health. The System PumiI Record must
be submitted to the local Board of Health or other approving authority.
A. Faolllty Information
Important
yy m aw out I., System Location: 1
form:on the
computer,use
only khe tab key Add °
to move your --
do not City wn state Zip Code
use the retum
kleyl-, 2. System Owner
Name
MW , r,_r Address(If different from location)
CktyllOwn State Zlp Code
Telephone Number F
B. Pumping Record
Date of Pumping 24M 2, Quantity Pumped: Gallons
1, P g Date
3. Type of system: [] cesspool(s) Septic Tank Q Tight Tank
other(describe): -
A ,y
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5, Condition of System:
t3 Pu ped
4 //V��ehide license Number
mpsny
7. Location Or�contents were disposed, m ��
- ..
I E- �J--U
of 4 Date
http://www,mass.gov/dep/waterlapprovalsAStorms,htm#I aspect
t5tom*d000 06103 system Pumping Record+Page t of 1
Commonwealth of Massachusetts RECEIVED
City/Town of No Andover A11 0 ?013
o System Pumping Record TOWN OF NOR d H ANOOVER
rt Form 4 HEALTH DEPARTKAPMT
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 CIVIR 15,351,
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab J 0
key to move your Address _
cursor-do not No Andover Ma
use the return
key. City/Town State Zip Code
VQ 2. System Owner:
Name
ream
Address(if different from location)
City/Town State Zip Code
—Telephone Number
B. Pumping Record
1. Date of Pumping 2� 2. Quantity Pumped: /600
Date Gallons
3. Type of system: F-1 Cesspool(s) Septic Tank F-1 Tight Tank El Grease Trap
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes [I No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
qwc� ,
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
.Stewart's Pre-treatment Punta 20 So. Mill Bradford, Ma 01835
u gf-H, auler Date
5 Sig tore of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record-Page 1 of 1