HomeMy WebLinkAboutSeptic Pumping Slip - 284 BRADFORD STREET 10/13/2015 i
Commonwealth of Massachusetts
W City/Town of No.Andover
System umpin 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 CMR 15.351.
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A. Facility Information �� ""�"� ��'°
Important: ,"n±� b
When filling out 1. System L ation:
forms on the �. t9 t u I8'��BC �„I
computer, use C
-o
onl the tab key Address
Y Y
to move your No.Andover Ma 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
tab ❑ �� � ��
Name
�® Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date r/ 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:
6. stem Pumped By:
me Vehicle License Number
Stewart's Septic Service
Company t)
Location where contents were disposed:
S wart's Pre-tr ment Plant, 20 So. Mill Bradford, Ma 01835
ignature auler Date
Signature , eceiving Facility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
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DEP•has provided hits form�for�use by local oards of Health, The Sys �em Pumping Record mss(
be :ubmlttad to th®.local'Board of Health or ther
' °y(Jtin"q a 0 rlty,
A, Fgollty Inf®ri tm
OF NORTI H ANDC)VER
HEIALT� DER
;*,Mw fuun9 out 1 r. System Location; . .�„ .
forms on the` '
'C
only the tab key Address .•' `
to mono your �r- c� ✓ °
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'Owner; ' r`
Name . .,. --_
Addrasi(If different from location) _.
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Telephone Number
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r«� pake'of Pumping Qua Pumped:
Dale 2. �ntity
G 'lions
30: Type pf system, ❑ Cesspool(s) Septic Tank
` , <• ❑ Tight Tank
• `` ❑FOth®r(descrlba) ��
Effluent Tee Fliter pros®nt7 ❑ Yes If es wa
.., Y s It cleaned? ❑ Yes ❑ No
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f�F ` 7r;'' Localflon where contents were dipcsed;
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t5forrM.doa 08/Q3
r Syalem Pumping Record Page i of 1
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Commonwealth of Massachusetts
r�
City/Town,.. of NORTH
AfVDOV s A ACI�IJSETTS
System Puimping Record
Form 4
DEP has provided this form for use by local Boards of Health. T e_Sy ,te.m_P.um.p ng, d mu
be submitted to the local Board of Health or other approving aut ority' ��,'� 'yVE
A. Facility Information —
Important:
D EC 6 2006
When filling out 1. System Location:
forms on the
u r -llv�l.ai��l
computer, use ,,,
only the tab key Address
to move your
cursor-do not —____—
use the return City/Town __.t_l-- -- ----
State Zip Coda
key.
2. System Owner
Name
Address(if different from location) -- --
Cityrrown
State ---- —
Zip Code
Tele P h e 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 ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Sy em Pumped By:
Name
Vehicle License Number
��. � cat a �l�°'-/.r�c1•
Company /I
7. Location where contents were disposed:
...
A✓LG( r- -------_---- Date
http://www.mass,gov/dep/water/ provals/t5 forms,htm#inspect
t5form4.doc-06/03
System Pumping Record -Page 1 of 1
R
_.
TOWN OFNORTFI ANDOVER
SYSTEM PUMPING RECORD
DA 1'I
STEM OWNER& ADDRESS SYSTEM LOCATION
84 -
F�
DA'I'E OF Ph
JMT'IN(;: _"—r? `f---__QUAN'I"I'I'Y PUMP} I.);
CESSPOOL NO I S Septic Tani: NO YES
NATURE OF SERVICE: ROUTINE— —EMERGENCY
OBSERVATIONS:
"IONS:
GOOD CONDITION FLJI-L T'()COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACI-IFIE;I..I)RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER O`E'I IER EXPLAIN ~ ""
,y tem Pr.rrrrlyecl by _
` G
C:"OMMEN"I'S;
r �
1f
C'C)N'EE:N"I"S`I'ItANSIry'E:RIdED'1"C;>
ii
TOWN OF NORTHANDOVER
S`Y.,STEM PUMPING RECOFLD
) l a I'EM OWNER & ADDRESS SYSTEM LOCATION —�
,._ w
d (eXOMPIe: Ief� from of house)
OF PUMPINC; .w "
.,�.:. ��""�" QUANTITY P U tYt P CD L L�
(. i:'.).�I'OOL; NO YES SEPTIC TANK. NO YES .
4.
-\]'U RE OF SERVICE; ROUTINE EMERCENCY
llI F RVAT10NS; ,.-
000D CONDITION. FULL TO COYER
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK .
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER ,O. HFR (EXPLAIN)
LM PUMPED BY;
CU I "y I CNTS:
UN I'k'NTr 7'RANSFERRED To.
�I
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
- (example: left front of house)
d
..ate
DATE OF PUMPING: ) '-� ,QUANTITY PUMPED "_GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO
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)
SYSTEM PUMPED BY:
i
COMMENTS:
4
CONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
9 �" Ik
ATE, 4-(9/
1
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
(example: left front of house)
Yid' „✓
p
MATE OF PUMPING: a'I V (,QUANTITY PUMP
E'D L ° GALLONS
1
CESSPOOL:,NO
YES SEPTIC TANK: NO YES
t�NATU
RE OF SERVICE: ROUTINE
PSERVATIONS:
GOOD CONDITIONS
FULL TO COVER
HEAVY GREASE
I� � BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER_ OTHER (EXPLAIN)
r; f� ; 1 I 'ISXS�ENI PUMPED BY:
Lc-
� MMENTSi'
�0I�� r
s FC 11'� �1�'V fl��lf< R���•,M �I
� •1, n III
r `
NTEN S
TRANSFERRED TO:
AO,
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iy
1
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FO IM 4 a SYSTEM I'UNHILNG RECORD }
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Contnton%realth op� g f''//��Massachusetts p
i
, 'ysferrt ''trrlt , rt Recor
ti�sleiii� ��� 16 ��stc►1r �(-)Ca t1oir
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Date of Pumping Qu,antity Pumped:
Cesspool: No � ties rrntir 't not tJr. � Yes
a, '
System Pumped by: K License �:
t -- ,
Contents transferred to:
Date Inspector
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