HomeMy WebLinkAboutSeptic Pumping Slip - 1220 SALEM STREET 8/31/2015 rv.'.mu OA I .WiwmM. �nsavW �� 12uipA'' idnn0.r.
I�
Commonwealth of Massachusetts
j n'� t ° 11 3
City/Town of .0 Record IVC)Rl°H AIV®OW . AL'T 1�� ��'FIARrMw NT-.
a -- -- System Pumping
Form 4
MM
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 -
only the tab key Address / f*
to move your
cursor-do not City[Town State Zip code
use the return
key. 2. Syste. Owner:
Name y
Address(if different from location
City/Town State Zip Cod
Telephone Number
B. Pumping Record
1. Date of Pumping 1 te 2. Quantity Pumped: Gallo ---
Da
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 XNo
5. Condition of System:
6. System Pumped By:
T7 ul�le6
— L
Name Vehicle License Number
Company
7. Location where contents were disposed: J
Sign tuf'" o ,..�uler�� """;��� �-- Date
Sig'�ture of Receiving Facility — Date
t5#orm4.doc•03/06 System Pumping Record•Page 1 of 1
I
i
Commonwealth of Massachusetts
City/Town of RECEIVED z
- - System Pumping Record NORTH ANDOVE
JUN Form 4
DEP has provided this form for use by local Boards of Health. Other forms m 7ANAinformation must be substantially the same as that provided here. Before usin
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:
� stem Location:
1 S
When filling out Y
forms on the T
computer,use —__---- ---------- _—_ i
only the tab key f
to move your Address d P
cursor-do not City/Town State Zip C
use the return
key. Owner:
2. System ,
Name
Address(if different from location)
— -- -- — State --- —-- Zip Code
City/Town ----_---
Telephone Number
B. Pumping Record
w ` —�- — 2. Quantity Pumped: Gallons --
1. Date of Pumping Date
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
i
❑ Other(describe): --- ---- ----- -- --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes VNo
5. Condition of System:
G
6. System Pumped By: ,
Name
---- -- Vehicle License Number
Company
7. Location where contents were disposed:
-- ------- ----
_
Signature of Hauler ----�----- --- �"°t�'✓C� r(°"��
Signature of Receiving Facility Date
System Pumping Record•Page 1 of 1
t5form4.doc•03/06
Commonwealth of Massachusetts t
W City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4 \J
A,
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 approvin
A. Facility Information
Important:
When filling out 1. System Location:
computer,use o � s ✓1 '' ��P 9itC L6nt
m ik IG E F
forms the j r � I .k
p I FaG"
only the tab key Address
to move your "A)., fq r
cursor-do not
use the return City/Town State Zip Code
key' 2. System,Owner:
r �
Name
Address(if different from location)
City/Town State Zip Code _
Telephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped: /6-6
Date Gallons
3. Type of system: ❑ Cesspool(s) [a) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee 'f=ilter present? N' Yes ❑ No If yes, was it cleaned? 19)Yes ❑ No
5. Condition of System:
C,1" _
6. System Pumped /By:
fn-'k' lid�7r1 Vehicle 7 .._
Name 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
\' `CO& It ilth of Massachusetts
t
'. iCity/Town� of NORTH ANDOVER MAC A�H"C1t S
1 - n,
system' ' P66ping Record . 6 200G
,,Form 4 l
DEP has provided this form for use by local Boards of Healt .o 'ffe' sterh- umpfng' ecord mu;
be submitted to the local Board of Health or other approving authority.
A. Facility Information -
Important;
When filling out 1. System Location:
forms on --- _t
only the tab key
omputer, use C ".t_' , ._ = � ---
Address
to move your
cursor•do not City/Town
'—- —' --- -- — -
use the return State Zip Code
key. 2. System Owner;
Name
aCi _._----.._... --
"°" Address(If different from location) _�•-------._..____...__._____.___.__,..__._. I
C1ty/Town __ ___._..._...__.__-•__-- State
Zip Code
.., ,
Telephone Number� � �-• ��
E ; Pumping Record
1. Date of Pumping �-
Date 2. ,Quantity Pumped: __.._.. ..
Gallons
Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank i
❑ Qther (describe): _..-____.....__ _.___...__._...----- .^..__..__....____._._.__..._-.___-_-.._......_..
4, Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
r
5. Condition of System:
6, Sy ern Pumped By:
ame Vehicle License Number
Company
7. Location where contents were disposed:
.yam„_]•C ,_-.`�...4tl•�� �L�G�.L.�� .........-..._.
Date _- — --------
http://Www.mas§;gov/dep/water/ provals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record - Page t of
i
,m.. ..� �.
DA tl —14 F7 11
( UANl'Il'Y PC.1 lf, �.
YES
NA !'t„ RE OF SHRN/Icl° , �Ca�E,l�"�1°�I�; Ew1`dURGUNC Y
OG SENNA°E'CONS:
(iCKA)C."ON'DE`E`EC: N F
"twnn Pu anE cd by f r' .
w
I
Ass _ _
j
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: r " , w kIx�,� � �03
SYSTEM OWNER, ADDRESS SYSTI E LOCATION
(example: left franc of house)
DATE OF PUMPING , �, QUANTITY PUMPED I ALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES V
NATURE OF SERVICE: ROUTINE EIYIERGENCY
OBSERVATIONS; �
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
STEM PUMPED
,
COMMENTS:
CONTENTS T SFE ED TO:
f
FORM U - LOT RELEASE FORM 50 y
I TRUCTIONS: This form is used to verify that all necessary approvals/wrmits from
ards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
**** *******************APPLICANT FILLS OUT THIS SECTION*
APPLICANT �J� S� PHONE
LOCATION: Assessors Map Number PARCEL
SUBDIVISION LOT (S)
r
STREET /2-d,o ST. NUMBER
USE ONLY*,.....,,. .*.t..*
RECD ENDATIONS OF TOWN AGENTS:
40kNSEVA4(TION ADMINI TRATOR DATE APPROVED 2
DATE REJECTED
COMMENTS S tUU ' �
TOWN PLANNER DATE APPROVED
h
1� DATE REJECTED
COMMENTS
FOOD INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
SEC SPECTOR-HEALTH DATE APPROVED �� J __
j' DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRJVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE