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HomeMy WebLinkAboutSeptic Pumping Slip - 46 WHITE BIRCH LANE 12/15/2015 �j•,'y ' � � ' +`41 ';y 1 .IS„}(�f)u1�4',I li�(,;�'��•.r,'x1�1�, , r. yK'�'��'L��S�h'.W T .'A•�1���n4Ir R ,,r ,r ? S MAC 'r w A ( olJ S y'f:��•w, •�+ �O �,�' i.����;�,�y�tj,':�wI J,K��l�l),}wirdq'li+y,�,�1•:ti!,y,�:v��l �`,�.I� ., � DEP has provided 0 i form for us© by local Boards of Health, The System pumpinp eccr� T be subml�ed to'the IOCaI Board of Health or other approying authorlty, I yJnforr tlorl .Jr,T I yl�l I�'g QUt ' � 'r �v ys4C7lll•�yVVU UonI ` only tho lxb key Address st�l . .; �y 4,,�tw�m;4 r',>�%:"'�''s;;,,�lJ;r;�,;,J ``''I'r"r'"�S'!•�'; � � .,,�' �1P Code r, .) y Yl' ip j'•.,;r,Y.:,r.'r`ti d`,y ('.fit I,,, , 1 r�',I','I! '° t;rrf ::f'k''l��'•Nun� ',I:;.,`r' r.',;r•'lt i+�t �'',t' � l Addrot�(IldlNer�nt rpm bcaUon) •��� C�yrTown ,., I, r Slate ;�ae -- I° Tolophono Number r 4 ' � t ' �• I, M I/I r L ,r1 14 I k'�y ')y[1"tp rrr l..V r.r' (,'•wl t'�li J'} r �Y �, "YFnF fioo°.N r Y , "\" `rll '.. w,. 'f 'ti"I+Y,°.l ,. ''1 ' qa.t� olPumpinq't ' � ' t 2, Quantity Pumped: w cillon4 31 T' Pf ayslem;; I, ® Cesspools) ptic Tank ❑ T19ht Tank ❑J.othar d ( s '' I w escrlb �; ( � '{ ,r/4{i�'�,iiC'I�j�YI'.ly't�i`"'�ii•'i''��' t1 .0 �v. ., � —._-- I ;P EfflUont Teti Pllie"( sent?.,❑ No as It cl . ,pfd Yes If yes weaned? 't �, +r �;•j��ra`�•.�/i�,(I;I��'/'(, $�'�t�r;j11,1+tf�l�l;it�t�� ❑ S 0 c Ye � �� Q.GsY3, >rl!,Stn�l. ,.�,.^"�. ......! iyr"'SSSI'�1 m 4� 6:,; Sy P�irnp®d 6y V�l w 'rl(J ,f� 'Il�w Vehicle Ll can}e Number , .0�r �,' ( ,,r��'��r yY,\�1w r���µ)/V�i �l rI�Y•'J'y��'V I'A`�/�K���/;�t{/j I��li)t!i � � r � .. •.r� ,'�{ tv , t•(,,`ti+ 1, w'dd 11.��.�,.�irr l;, 1�f �Iti,vy�S':,,� � � � � ', f, ,` o he a coolants we,r,e dl�posed it r I> I ' G,!tr��r,luf `'N,,.r I,�Il 1• !iS�w„ v 1 1 , 'y, r�J I,v'Ir"I ,r+, ',1 h�/I y V'« � +� 1Y• `11 k,t "RekJ11 i /��"l'-�' � ✓a �, i Orr ,h ti•�Jn d� 'S,ili. I ✓111a', '!;'r t�{"1}� r;^,p,i r� � , tr�r?;��y,,r.l:,,..�•$IQni W1 1iUl9���/ttilf?iY,,,��..,,t.� pGl1 tiPJhwrw mass,govid�plwatar/approvaJs/t5,(orms,htm#Inspect lSfG(f1i4,doG''�Q,� Syrlom Pumping Rscom TOWN OF NORTH ANDOVER SYSTEM PUMPING R..ECOR.D 1 �1 STEM OWNER & ADDRESS SYSTEM LOCATION (example. left front of house) DATE OF PUMPING. QUANTITY PUMPED �� > CALLU C. i 1)00L: NO YES SEPTIC TANK. NO YES t i �.ATURE OF SERVICE. ROUTINE EMERGENCY \ H S F R V A T I O N S: r GOOD CONDITION FULL TO COVED HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OHER (EXPLAIN) i ,)Y"TLM PUMPED BY: C. U ti 1.M EN T S U.N"1 ENTI ` RANSFERRED 'T'0. REECEMEWF Commonwealth of Massachusetts Cityjown of No Andover JUN '10 2013 System Pumping Record st 'TOW'N OF NORTH ANDOVER Form 4 V L! T m ANDOVER FHE HEALTH T H D E P A JRTME N 7' 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 forms I System Location: on the computer, > use only the tab klhlk key to move your Address cursor-do not No andover Ma use the return key. Cityfrown State Zip Code 2. System Owner: VQ . -k-1 Name mom Address(if different from location) Cityfrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping &'.'Wantity Pumped,, (5ate Gallons 3. Type of system: ❑ Cesspool(s) eA-e`ptiic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 61, o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Sy 7�tem: 6. System Pumped y: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc-03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of A/0 yzv System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Othef 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 day,,,.,from the pumping date in accordance with 310 CIVIR 15.351, A. Facility Information RECEIVED Important:When filling out forms 1. S se Loca *on: AJN 15 on the computer, use only the tab key to move your A kre TOWN 0F1q0TTTR7MDrJVM- f, Dr i,Ak,I W-N cursor move not HEAL use the return key. City/Town State Zip Code Q2. System Owner: Name Address(if different from location) City/Town State Zip Code ­ ­... -_—------------Telephone Number B. Pumping Record , IS60 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) R/Septic Tank ❑ Tight Tank F-1 Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? F-1 Yes F-1 No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System ped By: Na Vehicle License Number St -Septic Seew, Co any 7 ✓(ocation where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc-03/06 System Pumping Record-Page 1 of 1