HomeMy WebLinkAbout- Septic Pumping Slip - 43 OXBOW CIRCLE 10/12/2018 Commonwealth of Massachusetts
City/Town of North 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 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 1 <, (,; - V C
.......... ...............................
key to move your Address
cursor-do not North Andover
use the return ---. __....... ....
key. CityfTown State Zip Code
2. System Owner:
.....................
Name
raridn
_Address(if different-from-location)
—------
CityfTown State Zip Code
Telephone Number
B. Pumping Record
/ V,e"? j
1, Date of Pumping 2. Quantity Pumped:
Date Gallons
3, Component: El Cesspool(s) 0 Septic Tank El Tight Tank 0 Grease Trap
El Other(describe):
4. Effluent Tee Filter present? 0 Yes DA0 If yes, was it cleaned? El Yes F] No
5. Observed dition of component pumped:
77
.............
6. Sytm Pumped Ty;
... ..........
Name Vehicle License Number
Stewarts Septic 58 So Kimball St Bradford Ma
...........
Company
7. Location where contents were disposed:
20 so mifll s t bradford nia -------------—---------
Signature of lauler Date
. .. . ........ --------------------
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11112 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
0 ! �j M'Mm un is 4M'
_ w City/Town of North Andover
a /d System Pumping Record trc
Form 4 TOWN
��u F � 1IA raT.1�°
DEP has provided this form for use by local Boards of Health. Other fo r"Tf%7'bd'w'"d" b"Ot"mtl
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 1. System Location: -
forms on the /
computer, use __._ 44. ....�_..._..—..w...._. _
only the tab key Address
to move your No.Andover Ma 01845
cursor-do not .-......... _...,_.—__...... --......__ __w.. _.._.
use the return City/Town State Zip Code
key. 2. System a n r:
Name
reuun Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping at 2. Quantity Pumped: 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:
& S stem Purred By:
Name Vehicle License Number
Stewart's Semitic Service
Company
7. Location where contents were disposed:
art's Pre-tr ptment Plant, 20 So, Mill Bradford, Ma 01835 —. _.._—....._ —...-_—.....
Date
g ature of Haul
9
Signature of R eiving Facility — — Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts'
City/Town of No Andover
N _ r
Ic System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health."Oth r orms m y'be �f$ed t 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:
on the computer,
�fC
use only the tab ,• `--'`�"p
key to move your Address
cursor-do not No Andover Ma
use the return
key. City/Town State Zip Code
2. System Ownerr..V-
Name
� 4
ream
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping bo /j 2. Quantity Pumped: ._...
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:
G-2/
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
------
Signature of - —
y-�Gtler.------��-�-~�--�
. ..A' Date
eS`Lwawr"fo R ewmg acil€ty
t5form4.doc•03106 System Pumping Record-Page 1 of 1
` 1J9,;cUJAVu l06101slaAblddP �0 �°
1, ! ,Vyd i
•�ri I III
;o9Sbds1A Dh{;FjU�?U641614R�
;�fi;1,1'�j,Jlif�'}+�f�•14y(�� j j'1�"'�,�i'",t�;P ►tl��"'1 jl/,� "'H I,,'�� I�;'r •
1,^.. / t r1%,'�c��i,I,1�11'1 I �Al���{`� 1'IAA(Jp;i l�1,/',,•I„I/,,'
11W
Itl'ru,
t
low'i�r'jh�t;l
$ }� Imo' (,C6U44�J II S4•�' 'tA�( �,,' °lt�,�1 (art'i1���ia''t,I,[,,''/1'rl�'�li�tl�y ',1 Ie %,.I,;�, ,
I� ON cox U L1U04"d'111l� 61� UQhrir riu:,l;
!1 t_ YU6j JOOJO �iJd000tf6 + .I+•1, .t
� �� '1`,dU�dwnd 14 4100
) 9/ �.II 5" .1"1I�'� �I,1111,,'1�'„I�1°!`I
�^ duinl ,�g' ;'
10 r,
r.,
I�
A
�'�t>�66
ul
It1� 'y
" # �t 9Q�rw io v�'�ov t,,1 r>rtog raabj � ,.6
10611 lug 1 ' r�
��.��:� ��, �� � r t 1 n►f yore I}
7 Ott,r,l� 11�76
'�^'/�'�
P '
t Q l/ d��4r03
S" "✓ ;,
to
WOW w`-
,v ev,ti,<zS#`,°�� °.
�,,., / .: ,
,rl I , r4/ 4 L yI� 1q, 1: r'ta•
�'L•7��"5���1�1��`tl����
y M'1!nni�
• D _P„ �X/��M1 t�K�i7Ai�.r,Ilrr,V•r1 ��yy f'�L h�
.t •J.t^S l+ � r �y� •••� ' , `�/,"✓`,V�.r 1 ♦�' 1�1 1�5./ 9 '�',N�,,dro✓ '•"w' .
I y:},t'r,, t i ra•"ft„ ,�( :rl I171,��P4;ta�`'�.lY��y'jV's\`tl ill rtrl• I .. .r •
>� r �,�, 5. »,,1 ?jr•tr,,, MAY A .9 200
rV�� �J r,,�d.,. l�ldw,{cAr,'iti•l,!i`f`,H„}•;;uw,Vlht,?'{ ' r ,, ,
bl~P,,has provfdo'd Ni form for 686 by local Boards of Healt '
':bv subml�t6d to s local Boa P or lRecor rr.
rd of Hoa th other approyin L P ARIW EN11'
A; Facll4jnfort"Oon
{
,;,W t uno aut 1 , System L6cakJlye
cn;
the (ab Uy Add(e$r �
to mavo year ,rtArlAe k
.cxuxor�do P14f, {" Clly/fc�r(t
„ 'ua4'lh4"r �'otum � Jll r,'l y,;•;,`; '`.;`t,,. Strat® "'�.
,
,t•."k8 u' vd��.,r y,•prr ., 5 A:)IK'^ts•+`•'i,. ,.r r ., 'i,' .,, .
i.2.!c:,;5 St8P�1 OWn6f�v''�E�'�, �;•, ' , , ,��� r-. r .
' �F y��}�+ ,"�`I, i;¢`��'lrr�t�'lJLI.4:t,l,II �1(,rnli/tfa�:+',1•t �
' .r r,l. ad t ,r,•,rt M,�;',4',f:b}:�r,iwf °i;}',,i "�'�t�' .� P
, ,f,•.^y+:r �i'w,.•.",IJ,a•�b ,f r(, "••ItJ/'t�e7nt9�'`'t,i5� I,+„,/•.Y" 'drd;a„vny•, �•
7I4+,afr 4r•,
Add.( (If dlNorgnt ran bcatlon) . ,
La to _ �
Code
Tolephono Nurnbor
,
1 �
r ' ,r, rr �1• �� tip�q. �rT •V VI dt`
,
t ' •„ t 7 rl Ca CV
11 Dal of PU J` n Q Pumped:
m Or�Io 2, uanUty
TypQ vt.syst�ir�i�; `�,'❑ � ' Cesspo�oi(s) ,S ptPo Tank ❑ Tight Tank
Other
.`,• I r v yIJ,v�t
tl e6 FIlte(p,s.�n.�7,,ED Yas o It yes, was If oleaned7 ❑ Yes (� No
7 J;t11r rry),f ., t'r r t't4;•
Fr�l!r�✓•,i[�•:u',!�;t/,a.+�`�y'r,"r �fmt
;' 1 `4a'i'ru."''t;'�i� CvntllU�n` f,•'9 i;���'�"r ''
JI4!!!','`'�/r''},1J4(:b51�I.1 ii,,'�.i�tl•!,'j`(7 i1,) '
., ...., ' S ,I :f1 '�.I•Spt ,�YIC(`4 Uk3;f 114! 4L'y`,(i�l•L,t' 1,t1� •
PmpQd s�
' r a' 1 t, "45 ,`"l 011, ra111V•i\1?I�rl ll i"q�t S'� rl Y� f S." � �,,,,y,
,,1:, ��, �Ni'''J' +I ti{'i.( �"`�l'{1tl rI• ^�� I}f�,L ti:,Gll ,r5 �I ,�, L +lr4�r �' YB P �U�� � Nvftot
'S•k`f' w� 'y,4'l`y"C"��'�'t� t(f, �`jJ�' ,fl,'�''• lL' ''�'1 � �f�� q(",//�/"�/,�/��JJ� �,�/y,��//��
AV '•'�rti�w fS�rrfi� I rr 1 �"�,' � 'L j � it "Al ' ((rllAll r i
„ J F,,,• ,. ,.7t a C or fJgn,whcr� ccr7lanGs e a.dl posed;
r
� '1, I, )' �,:7"i:,ae'r 1.'.:'i.�rr��S •,,r,.dirl�l+ ,11;r�. :�' �' �� �
', p'.'y i �!, �` �),,A ! � I /I / Arr 1 ' •, '7 ,'tj��,j l'4r('la", +":�..�L�.i,�'�: L,+
YU " �r,•`;i(fu/Y"'"'ryr,
hUPVAr>4.ma",gov/dophralyr/appr4vaJsJl4.forms,htm#Pnspect
L,�7.'VM l I II.LJ N✓'r'�vr q'•J
y:torn Pam Q � I
•
,
p n OC4 Fi a I .," ,
� F
r (I y
('C)WN
SYST --�
µ
Y!~"�,• >vauc 1 cryA "
1+n r V K E x Q
vbj;:�xv DCtm ._.,., r..r..m
O ft VLL f"u L:(iN. rr,
ROM. r,.w, ��i�,-C'KP1�1.Q KVNS�yc'M,
g+� OMB , (OLID8 Pt,t?gD�l3
�4L CD Cry!Vt YC7�X
(T "IEAL�
NG 4
TOWN OF NORTH ANDOVEI-�
"'YSTEM PUMPING FEE COJ�D
Y,S T E N/l L,0 1 C)N
OWNER & ADD RE, SS
01
2,
----------- ------------ ------
Q U A N T I TY P U N1 P C L) OF PUMPING:
l'O 0 L N 0 Y E S S C PT'I C TANK: N 0 Y LS
ti R E OF SERVICE: ROUTINE EN E R C EN C'Y
J!S>r1f V ;\,Fi 0 N S:
COOD CONDITION b'ULL TO COVE;Z
f-I FA V Y C R E A S C 13 A F F L ES I N L,\
ROOTS LEACHFIELD [ZUNUACX ,
[-', XCE.SSIVE SOLMS F 1,0 0 D ED
SOLIDS CARRYOVER Oj�Hf, R (E,'XPL,A )N.)
---------
—-----------
----------
T) A N S F C I Z Z E D TO
V L(VJ/17�! VV.JV JVGJtJO611 :�ICI^7Hfc.1/HI"IIJV VGK. 1""H47C V.3
Y
Avn6ver 2.,C2s. W RToS IC
TANK oin 5� 47 Ru $ CE
A/®rl A no 4vo., 35
35
W-0 v i c 11 ,Gl-106 4 978-372-7471
mom OP
CF
AD_ GAL -
V-c
I�5va
�- lob
L&
^' r Cc,?,5 !
✓ �ro L¢Yu 13 kl?
1660