HomeMy WebLinkAboutSeptic Pumping Slip - 38 WHITE BIRCH LANE 12/15/2015 0Q`nlmbnweaith of Massachusetts
0 `.' ity/T0wn '6'f Tip ANDOVER
y tern' U'M' Redord
Form 4
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DEP has provided this form for use b local Boards of Healt � Thy�tem Putt�ping���`ecord mu;
be submitted to the local Board of Health or other approving authority.
A. Facility Information � N.
Important:
When ruing out 1. System Location:
forms on the " ..m
computer, use a _ � / •
y __ .__.._—___
only he tab key Address ' _._..___•._.- --
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to move our
cursor-do not
use the return City/Town
key. State —' -- -- -
Zip Code
2. System Owner: ,.,......_
Name __—_ _ ----------- -- ._..
--
Address(if different from location)
CIty/Town State -------"— Zip Code -
Telephone Nu mbe
�
r --
B. Pumping Record --
Y7:
1, Date of Pumping ®at -- 2, quantity Pumped: ="�`
Gallons
� _ Type of system, ❑ Cesspool(s) �,Q eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? ❑ Yes 6"
p If yes, was it cleaned? ❑ Yes °j
5. Condition of System:
6, Sy em Pumped Sy:
t Q Vehicle License,Number ---•__..__._
�� .
Company
7. Location where contents were disposed
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SI ature of
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t5form4.doc,06/03
System Pumping Record-Page 1 of i
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Sys:Rm Location:
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Commonw Itl°r �f M �chusetts
\Q
ity cwn'Qf N ANDOVER,NDOV R MASSACHUSETTS
System Plumping Record.. �.
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumpkng Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important.
When filling out 1. System Location,
forms on the
computer,use
only the tab key Address .a yy .
to move your I 9
cursor•do -t Cityffown State Zip Code
use the retum
key,__ 2. System Owner:
Name
Mw Address(If different from location)
Cltyrrown State Zip Code
Telephone Number
B. Pumping Record
47 4)
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:
e, System Pumped By,
Im e Ve icle License Number
_t
Company
7. Location w ere contents were disposed:
Signature of Hauler Date
http:/twww.mass.gov/dept water/approvals/t5forms.htm#inspect
t5forrn4.docr OW3 System Pumping Record•Page 1 of 1
i
Commonwealth of Massachusetts
- fa City/Town of North Andover
System u i Record
Form 4 `u;...°.
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location: C-
on the computer, �Q 1� b
� t
v) �,an
use only the tab J� J I , t`
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
rerrn
Address(if different from location)
.......... _ ..... --
City/Town State Zip Code
Telephone Number
B. Pumping Record
r.-
1. Date of Pumping .� 2. Quantity Pumped:
Date 2. Gallons
3. Type of system: ❑ Cesspool(s) J 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:
f
- LASS C
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
Signatur f Hauler_ ______ _ w,., Date
Signatur - - eceiving Fability Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
St OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
�IA 1:h--
rt'(- ei,(4,
DATE OF PUMPING: 1-114�zoa QUANTITY PUMPED GALLONS
('I,-'SSI)OOI-: NO _ YES SEPTIC TANK: NO Y I:S
NATURE OFSERVICE: ROUTINE EMERGENCY
0 13 S F R VATI 0 N S:
GOOD CONDITION FULL TO COVER
I
ffl-"AVY GRE"\S1,- BAFFLES IN Pt,A('E
ROOTS LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: y','z
(-'O.1 l."vI ENTS:
(-,'0 N'1'1,'N'I'S TRA N S F E R RE 1) TO:
i
TOWN OF
SYSTEM PUMPING RECORD
_ t
DATE
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
DATE OF PUMPING: 4^� QUANTITY PUMPED : I f 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)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: O.L.S.® Lowell Waste
P '"fir�V YI,
_._ Commonwealth of Massachusetts
City/Town of No Andover ��°"�� ?��1��
0
System~ Pumping Record ?
� I n i u��lu,iaa�c�����t
Form 4
i
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, //
use only the tab F � _� � ....- /`� -- - --
key to move your Address
cursor-do not No Andover _ MA
use the return
key. City/Town State Zip Code
Q2. System Owner:
Name
iensn
Address(if different from location)
City/Town State Zip Code ---
Telephone Number
B. Pumping Record
1. Date of Pumping — � 2. Quantity Pumped: /560
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 KIT
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 No.Andover
System Pumping Record
Form 4 OF
ANDOVER
r
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 t
c
Ln
omputer,use
only the tab key Address
to move your No.Andover Ma 01845
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
Name
I
' Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record I 01I /S-0
1. Date of Pumping batJ 1 1 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
i
5. Condition of System:
6. Sy ,e, Pu et
Na Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
wart' P -reatment Plant, 20 So. Mill Bradford, Ma 01835
nature o Hau rr Date
o
Signature of a Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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