HomeMy WebLinkAboutMiscellaneous - 74 WILLOW RIDGE ROAD 8/24/2015 (2) 1
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Commonwealth of Massachusetts
City/Town of North Andover �. d
ItG)C allAiack���Kl��a ,
a System Pumping Record s��aw a�a a�aawi a ��idbu4ra ira
Fora 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:
on the computer, f '�
use only the tab
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 _
arum
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Gallons 2. Quantity Pumped. ' °
3. Type of system: ❑ Cesspool(s) IxSeptic 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. S stem Pumped By:
...
e Vehicle License Number
Ste wart's Septic Service
- ------ -
Company
7. Location where contents were disposed:
,,_S art's Pre-treatment lant, 20 So. Mill Bradford, Ma 01835
S nature of Hg r _.___._ --.----.- Date
Signature ofRacei6ng Facility Date
t5form4.doc•03/06 System Pumping Record^Page 1 of 1
Commonwealth of Massachusetts
City/Town of No.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 1. System Location'.
forms on the
computer, use
only the tab key Address I
to move your No.Andover Ma 01886
cursor-do not City/Town State Zip Code
use the return
key.
"IrR,',E
2. System Owner: i J
Name
OR
{�1 1 - A 1, ,
Address(if different from location) N
EE A�1 1 1, A,!y V1 N
City/Town State Zip Code
Telephone Number
B. Pumping Record 2 Quantity Pumped:
1. Date of Pumping 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:
6. System Pumped By:
zru
N iffi—e Vehicle License Number
Stewart's Septic Service
Company
1117. LocatiorNwhere contents were disposed:
St re-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler vev— Da/te ,_ 9
Signature of Receiving Facility Date I
t5form4.doc-03106 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts FE
City/Town of No. Andover
Y I AY
0
System Pumping Record TON OF"NM u I 1 ANDOVER
Form 4
t RL: t d H DU I IAR 8 8 k l l
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 1. System Location:
forms on the
computer, use 74 willow Ridge Rd
only the tab key Address
to move your No. Andover Ma 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
2k, �rb Mcginnis
Name
eW Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 4/15/11 2. Quantity Pumped: 1000
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:
Good Condition
6. ys ,m Pumped By(: X,W.. ,
Name Vehicle License Number
Stewart's Septic Service
Company
7. Locati" n where conten s were disposed:
S 6w rt"s Pre-treat / t Plant, 20 So. Mill Bradford, Ma 01835
ig a of Haul r Date
Signature of Receivtgtacilityl Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
I
Commonwealth of Massachusetts
v City/Town of NORTH ND VER,-MASSACH US ETTS I
n n 4
System Pumping Record ���.��' :1. ����� 1
s` Form 4Nccl
ENT
DEP has provided this form for use by local Boards of He th-,.w�-he-system r'I g Record must
be submitted to the local Board of Health or other approving authority.
I
A. Facility Information
Important:
When filling out 1. System Location:
forms the
computer,use 1`"► l.-l.� -1-�.
only the tab key Address
to move your Q s �p
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
a° Name
+� Address(if different from location)
w.
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes V_J No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Sy em Pumped By:
o bgM (P LG `b2 - M 1=1
Npwe 0 Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &,�DDRESS SYSTEM LOCATION
(example: left front of house)
. )d t `
DATE OF PUMPING: QUANTITY PUMPED ,) GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
i
SYSTEA1 PUMPED BY: � � n/7,/,, ✓� � '��A�
COMMENTS:
CONTENTS TRANSFERRED TO: