HomeMy WebLinkAbout- Septic Pumping Slip - 29 PADDOCK LANE 10/29/2018 _ Commonwealth of Massachusetts a r013 d
City/Town of North Andover ` "
w
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location: �,', t -°"-
on the computer, iu Y 1
use only the tab I_1'--------------------------
-
key to move your Address
cursor-do not North Andover Ma 01845
use the return ....--- .. ...... ......... --
key. City/Town State Zip Code
2, System Owner:
.. ....-
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping {l 2. Quantity Pumped: - M, 0- 0
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:........................ qood ,
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stew= us..P.. -treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Haule afe
Signature of Re �
ivi g Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH 6NDOVER, MASSACHUSETTS
System Pumping Record
Form 4 ,
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:
forms onon out 1. System !_oration
computer,use
only the tab key Address
to move your ) e F_. ?
cursor-do not City/To n State Zip Code
use the return
key' . 2. System Owner:
Name
Address(If different from location)
Cltyfrown State Zip Code _._.._.
Telephone Number
B. Pumping Record
1. Date of Pumping oat --- 2. Quantity Pumped: f
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 ❑ No
5. Condition of System:
6. System Pumped By:
CAN me Vehicle License Number
Company
7. ocatia v\here contents were disposed: (k mmwp ry �.m7
Signature of Hauler Date ---
http:/twww.mass.gov/dep/water/approvals/tSform s.htm#Inspect
t5fumWdoc•06/03 System Pumping Record•Page 1 of 1
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System Pumping Record
Fo.rlll 4': -
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DER has provided this form for use by local Boards of Healt a ystem Pumping Record must
be submitted to the Iocal'Board of Health or other approving authority.
A. Facility Information
lmportant;
._When filling out 1 System Location:
forms on the
computer,use.
only the tab key Addresscursor-do not
m„ /
to move your
use the return City/Town State Zip Code
key,., . .
2.� System,Owner:
Name
Address(if different from location)
Clty/Town State Zip Code
9 ''
Telephone Number
` B. Pumping Record �r
1.' Date of Pumping cats 2. Quantity Pumped: Gallons
3,.,,1 pe of system: . ❑ Cesspool(s) EY'aeptic Tank ❑ Tight Tank
❑ Other(describe):
° w,µ 4, Effluent Tee Filter present? ❑ Yes ❑"No If yes, was It cleaned? ❑ Yes ❑ .No
•
5, Condition of System:
�u
6, S ern Pumped B
Y p Y
,
Name Vehicle License Number
a lvrd) Ana
Company
7; Location where contents•were disposed:
. G'dMa
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5fomm4,doc-06103 System Pumping Record•Page 1 of 1
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TOWN OF
DATE:- , __OqlN(' V 1 9 0
�('1 Af r h ,i
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example- left front of house)
ov .
BATE OF PUMPING: I QUANTITY PU IP'I D _ � .50 b GALLONS
CESSPOOL: NO YES SE PTIC TANK: NO YES
7
NATURE AE SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASEBAFFLES IN PLACE
ROOTS LEACHFILLD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVEII OTHER(EXPLAIN) -
SYSTEM PUMPED BY: Bateson Enterprises, Inca
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S. Lowell Waste
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
.DATE: ✓ (/„!",
`
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
f . . J-f
99
,
f ; DATE OF PUMPING:
QUANTITY PUMPED t 1 GALLONS
CESSPOOL: NO YES SEPTIC TANK:�_ . NO..� YES `v
NATURE OF SERVICE: ROUTINE, i;ME1iGENCY
r' QBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE _
ROOTS
LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
'eSYSTEM PUMPED BY: a'v
It h 4M � COMMENTS:
a
cw '
X.
I '
TRANSFERRED TO: / / j�
� f
f
0V
,X
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECOR
I'Pyl OWNER & ADDRESS 7—s
\Tc OF PuMPINC:-.-10 , (,'l QUANTITY PtJMP[-. Dz L
1'0 0 L: N 0 'y E S S C PT I C TA N K : N 0 L,S
A'I'URC OF SERVICE: ROUTINE FM ERG ENCY
H F:'R V ;\TIONS-
COOD CONDITION Fut-t- To covf-,,,'t
H FA V Y C R EA S C 13AFFLLS IN J)I.AC["
R 0 07's LEACHFIELD RLNI3ACK .
CXCESSIVE SOLIDS FL 0 0 D E D
SOLIDS CARRYOVER 0j4 H HP (E X fl L A J N.)
I L"A I)U M 1)C D B Y
U I 1:'N 1'S TI A N S F C, Z I ED TO