HomeMy WebLinkAboutSeptic Pumping Slip - 2201 SALEM STREET 9/17/2015 ^
^
Commonwealth Ma,,�sachusetts
��' r� y�� rf� Andover
City/Town�H8/[] `�/ North ^�Flmover
`System Pum��^�� Rec��rd '
` . -~
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may beuoed butthe
information must besubobanUaUy the same asthat 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 31OCK8R15.351.
A. x-wucnxuuy K0oUorm@|tUKDn /
�����
important:When
° �=
filling out forms 1 System Location:
on the computer, jU| 1 � �O1�
��on��e�� upp "°� ' ~
key m move your Address ��---------'--------------''-----------'-
cvmu do not TDYNNOFNORlHANDOVER
unoman�um '»u/u/ Andover
xay. City/Town State Zip Code
2. System Owner:
^rq ///(S's C� y1M^
wa�n ./ '------------'--------------------
Address(if different from location) ---'---- '---'---'- ---'-----------'-'------
City/Town �----------'—'-- -- ----'------------' -----
State Zip Code
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
|
-- ----' |
L�
Other(describe): ----------------------------__-_-____.___ _-
4. Effluent Tee Filter present? El Yes M~�(� If yes, was tdean8d? Fl Yes Fq.-No
5. Condition of System:
6. Syst Pumped By:
tic Vehicle License Number
�
Aewarl's
Company ------- -- |
7 Location where contents were disposed:
�
�~ "ewu t^ Pre-treatment Ma
Signature ofHauler ------- --�-----'--- --
Da ���-----
GignommnfRooaivingFaui|8y -'-- -----'--' �ate----------- --- -'
t5fonn4.umr0306
System Pumping Record`Page 1 of
Commonwealth of Massachusetts
ityaown of y r S ,
system
Pumping
Record fi�t�� iJ�P t! ur i ; 4f t
Form
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 su
the local Board of Health or other approving authority within 14 days from the Pumping in Emitted to
accordance with 310 CMR 16.351. p g date in
A. Information
Important:When
filling out forms I. System Location:
on the computer, C /
use only the tab (_) J
key to move your Address
cursor-do not
use the return No andover Ma
key, city/Town
Mate Zip Code
2, System Own
r6
Name i
Address(if different from location)
CityRown
State Zip Code
B. Pumping
Telephone Number .
r
1. Sate of Pumping pate Z. Quantity Pumped:
Gall ns
3. Type of system: ® Cesspool(s) Septic Tank
p El Tight Tank ® Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes No
If yes, was it cleaned? ® yes No
6. Condition of System:
6. System P p d By;
�
Name
Stewart's Vehla
Septic Service le Lt se Number
Company
7. Location where contents were disposed:
„,StWa if s' r6= tment Plant 20 So. Mill Bradford Ma 01335
' m bate
Signature of', ceiving Facility - Date
t5form4.doc•03/06 "
System Pumping Record•Page 1 of 1
I
Commonwealth of Massachusetts
City/Town of No andover i
System Pumping Record
yY Form 4
DEP has provided this form for use by local Boards of Health. Other forms maybe 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 R
filling out forms System-Location:
only he tab 1 S/„ to L❑
atlon:
on the computer,
Y
key to move your Address
cursor-do not No Andover Ma
use the return
1,ey, City/Town Stake Zip Code
rab 2. System Owner: � .�. ....,� ..,
,
t rv.• „�
Name
1
/BtLp11
Address(if different from location)
City/Town r. 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 ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes F'�""'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: c
6. i, tem Pumped By:
p y.
Na e""'" " Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stew rTs,Pre-treatment Plant 20 So, Mill Bradford, Ma 01835
Signature of Haul Date
Signature of e in Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
i
Commonwealth of Massachusetts
City/Town of North Andover
M System umpin Record
a
a` Forth 4 TOWN OF NO R714 ANDOVER
HEAL.°TH DNPARTMEur
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 Locati n:
forms on the
computer, use
only the tab key Ad-dress
to move your N.Andover Ma 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
wer OA4f�La)LA
ame
fey" Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
" kv)n
1. Date of Pumping " ' 2. Quantity Pumped:
ate Gallons
3. Type of system: ❑ Cesspool(s) eptic 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. ystem Pump d B "!n--nol I (A o
ame Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stew re-treatment Plant, 20 So. Mill Bradford, Ma 01835
ii —tu ul r Dat
"1
Signature o R Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
a
r+
t
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System unnping,Record
Form 4
DEP has provided this form for use by local Boards of HeIn pi ord must
be submitted to the local Board of Health or other approvi
A..Facility Information @ !y ° �' oI4
Important:on the
�s ,use y OCation; PN t7p NoR'Ttl ANkCVCft When filling out 1, S stem AV.t 4 i DPPAt3'T 'N f
m . 0
only the tab key Address
to move your ret - �;-n(A
use the ,
cursor•return not CitytTown State Zip Code`
key,. 2. System Owner:
Name
Address(It different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
h C'
1. , Date of Pumping Date 2, Quantity Pumped: Gallons
1 ,Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
{] Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If ye§','Was it cleaned? ❑ Yes ❑ No
5, Condition of System; t
6. ._System Pumped B -,_
0c
e 1j:
Vehicle License Number
Company
7. Location W4ere contents were disposed;
rx
gnat of Hauler Date "
--
http:/twww.mass.gov/depAvater/pl5r',oval&tt5forms.htm#lnspect
-06/03 ",. System Pumping Record-f
f
i
Commonwealth ®f Massachusetts
City/Town of � EI U .
M : o
W System Pumping Record M 0081
g
Form 4
' TOM)` N H ANDOVEf�
DEP has provided this form for use by local Boards of Health. Other f b!
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.
A. Facility Information
Important:
When filling out 1. System Loc10���
forms on the
computer, use
only the tab key Address
to move your
cursor-do not Cityfrown State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
3—_S-Z--
Telephone Number
B. Pumping ec r
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): -�
4. Effluent Tee Filter present? ❑ Yes Q Ito If yes, was it cleaned? ❑ Yes ❑ No
5, Condition of,Sy�em: t /, ). r
\j
6. System Pum y:
Name Vehicle License Number
Company
7. Location wh con ents were dis sed:
Signature H ul Date
t5form4.doc<06103 System Pumping Record a Page 1 of 1
Commonwealth of Massachusetts
City/Town of
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.
A. Facility Information
Important:
When filling out 1. Syste Location:
forms on the 4 -
<�� ---,
computer,use r
only the tab key Address
-z
to move your
cursor-don— Cityfr State Zip Code
use the return own
key.
2. System Owner:
Name
Address(if different from location)
City/Town state Zip Code
nc--> �,—
Telephone Number
B. Pumping Record
1. Date of Pumping Date r— WUG111tity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) B--Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0-06�- If yes, was it cleaned? ❑ Yes ❑ No
5. Con ition of Sy tem.-
\Ij
6. SysteyjPumped By
P
Name Vehicle License Number
Company
7. LocatZhere contents were disposed'.
Sign.4ur9toft'auler Date
t5form4,doc•06/03 System Pumping Record•Page 1 of 1
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