Loading...
HomeMy WebLinkAboutSeptic Pumping Slip - 45 WHITE BIRCH LANE 12/15/2015 ammo'6 I O Massachusetts City/Town of NORTH ANDOVERJ MASSACHUSE System u pinRecord .. t Form 4 , DEP has provided this form for use by local Boards of Health. The System Pumpi,+g Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: "n - ZJp forms on the=puter,use only the tab key Address )to move your ,,cursor•do not Cgfrown State Code use the return key,_° 2. System Owner: �1 � &4--h J 1 Name Address(If different tram location) City/Town State Zip Code Telephone Number B. Pumping Record /0.. 7//0 1. Date of Pumping Date 2, Quantity Pumped: Gallons 3, Type of system: ❑ Cesspool(s) 5,1teptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: f 6. System Pumped By: Vehicle License Number Company 7, Location v Pre contents were disposed; u/ Signature of Hauler pate http:/twww.mass.gov/dep/wafer/approvalMSforms,htm#inspect t5form4.doo-003 system Pumping Record-Page 1 of 1 1 i ❑ Commonwealth of Massachusetts V City/Town of North Andover � System Pumping Record fr rub 21 &0 Form 4 DEP has provided this form for use by local Boards of Health. Other forms rri1"y°beused bt �a information must be substantially the same as that provided here. Before using this form, check with your 1 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: u on the computer, se only the tab _ � � �p�~� _ „mod,I _ _......... ._.-_-.....-- key to move your Address cursor-do not North Andover Ma 01845 use the return key. City/Town State Zip Code j i 2. System Owner: tab Name -- -- Address(if different from location) - ... -----..._.._ City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: 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: E 6. tem Pumped By: : Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Steewart's Pre-treatment Plant 20 So. Mill Bradford, Ma 01835 lo"X natur of Hauler,-----7--- Date Sign ture of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 r.� { ,F�Ip•I V kl�`�+��Y11/yti u! r/, +yl r, r I , ,Y, I „4 r' 'w•� 1 r���Y,llr� 'y '• V S E ,�''''Krl, �, ,, '�1). ' N°�i�{{ �ari•4�1���'(� �'' "r;r�'.';���' q� �gp^ 11,1.�Y,,l ,,' .)�I,�)I�►IIY I Ii�I `'{ :1 ►I'i,t 'I Y � 200 , ©ePhlr prorld�dlhll rolls ror 41 r , vvrn11Ivd r to thr lo ch 8plrtr ' v n vv0 i' In p; ANDO 4111 l 4 A' Facliiry In(ofm�ilon. 1 ~� Y SY$;Vn lc ('on: l o—a I 14� ,l it l Ur l J I ' �dl14+ I d Irinl rtrn buVvn) I'. A"or T1 ,1 ralY-Rumping, �'�ord /G 00(o 91 Pvm�ln" $Opoc Ten, 7 ' • ' .;'Q�Olho)'(do�c,ribef '• rs�, ra-. r;,,EJ�M�a��ryol4�yl�lelJy�f,9l,tiont? �' yQ) Q No �Iy I IV • - j (/';,;;I II 41V;Q�fd�y9n �(,`SY, r,'r�'i'��' `-' r I } — • � ,1';,I('�'!''J/.JJII'll�'fl y !d;'y IJh" �� � r. Y /I ,Py'r�l p 6,c)11 ,1 �''1;1/�)nVj,,✓,11��6, rI1��Y J. I�'rl��y���l)i ��'� oca onl�rner I l� lyOG�Ilbnla oomoo: r,,•' y %„l� +� I'Ir')I,Y IVIyV r V r wr S�nl,kvl9lNivG(y�{;y,�l;l,',,,,III r U N.T . �������'' •:, lvl . .r ,.,ti, �;,`m O NOV 3 2008 ' EP'hoI Provided W; loan for eo wy ;o,or D 4' rrlllod fo ll�e local 8carc cf noa,rn p, � �� nP� 'R" a�¢�IJQ $Y3lom P. ,�.. Faculty Information �i'r�•,�' n; vJ'S19,^1 �VaUon: 04 nam''Y;' CirY/lorn 1,,no v �� r ., f l 0. (tl4Vf�r!nl rpm bcaUon) rolopnpn° N, Pot, ,.Pumpino Ra?,ord , - Ij Oars o! Pun) .TYPO P! 0 rn C699p001(y) pI�C Tens Tignl Ten,, (��OJ�sr (da9Cribs�` '� 7 ErtiiVan! Tae UIa(.P(p,w,r? n Yp9 ll Yes. i l µ ,'a� p aanao7 y — ( 1 I7 B SY p�1 Pti'mpsd 8y. a ,. 1 �r�(f�,fj,. �1 f,•�' �� 'n (.J !ji'J,;,':' VOhI '� ,".` i'%Y',r%^�4�',��f,��� iYJ �'(•( �l� '�r' 1; �� �� /� C19//�/1C�dn/11 h'�,:Tv01 'y I ;f' fi' ��",I'�i?,�,'r,,� / on.whore co�lanla'ware dlyposso: 'n�ww•rnasa.8ov/dsp�wtiiar/©pprowaJa/Iblorm1,n.mpin9Parl c "V1f �Yyq ' 1�`y'✓�1,.4j 't.�!yh: rp'��•,( ��,//��q�®.�{p','"�7',.{,p�,,ryg-,, .,. , . • l ' • '"k .tip`� y,� � C�I�''�"�t,�,�tl I��V' AC H US E`1�1" 1 r 1 ! �.�{•,� S7 '/,t;�✓,l �\'�r���Yf{•�•�l�1 rM t1����J��t�1Lt.��I� ' I (.. ••>�11.+.r �'v{{`�1 i�.i):•il,�f��;jft)llil�'r1 v1}.;n. ti, l�f {Ir r1,4. Yr:1 f!i. .. 1. ,, .• {l�-1 ,lr.,� r. l.,',L.Y..,r,'JC•,S.'`;`.p;",' p'+ ,yF D P,.has this form for use b local Boards,of Health p Y r The System Pumping Record r s be submitted to the local'Board of Health or other approving authority, A, Faculty lnforfOgtlon f, Win'ft111n�out <1.r'1-*,' System Location; on the .only the tnb key .• Address to Move our ,r CUlior•do(lot ''` '`usi'the'rotUm �` Clty!Tawn +; • �., .r Slate ZID Code Z". System Owner, t �w :Address If +•,�••�" I S • � � !r ( dlH9rent from location) CttyCroWM1 $late' Telephone Number g'y pu►�pjn� R�,yecord . . r �J, � r 'Y>.,,�jy��,7�,ll.l�'M( `'r,11a r'JII(.'l,;Y,��!.!`'tt�t Jt �.. , ''`• I :mow 1 . Datt3'of Pumpinq �Oal9 2. Quanklty Pumped. Gallons Typg ®(system, ❑. Cesspool(s) Septic Tank ❑ Tight Tank C�FOther(descrlbp), 4 Effluent Tee 'liter rQsant?' Yes a I y If cleaned? p sr was ❑ No >. 1 ❑ � f e Yes • , '�'. r' yl ../�ry/:'d lw r,J{, 71 ' !i,:,.;u�htyyq �i'. •�' • '''*t ` ' N'` �'VIj414�-• V $t(�f Ill l,'�1',.'�Y•, .• .. ..t:.• + 4. �.+NM j) • A 4^ 1 � r a• .,�Y/•,1 1zi<l 1+ r � - � �rw �,.w�'"Jw.,�^*d'�„�.'�, .., .. 't� ;ri'�.'.',";�{t 1 w'�{r(.i?)ys�;1;•rr';•.L' 1J�5 , .+ Y r f +l Yir'.�Y.;�YIfJ'v ra r i'r;'r l'ti�Gf jl•��a' ' , r ® ' Syr1 Pumped r',;'Y.',a�lri'. &mO•!.\'�:^,,i��l'l.;s• 'A}:i r'I•h r1V f }�Pi+•-!'�' +z„lY,, is r'3•���r ,,,. ,;%I}� fJ�';,i'� G��, �, vehlclo ucan#e Number }�tsY.��rrt '1��`r+�'r�'hV'�I'�t} f,o�;1 1'�YJ�:i�.' arjX' 'i'}`�� ;c, ��✓�. ..'r,J' ••i•”.l;Y.t{�,r, +',�`�. t'�•, y yNy+Yr}�� 1ri' '1't�!ll)'�:1' ,•a, ';/,� 1,�,.! av,�..• •r1.i tl�trjti{y'• ! • + , I ,'>y�+{t 1_;S{1 4 r,.s��.ily'rr�A�!�yF.f W�•;'�Jl��!jr.l��.�4/k Htll tIG i S 5.if lr I a � ., a.7r ..L�oca(!on wh®re contents ere did o LO W.,.. p sed, f.;�i.;�r+lvl+ Jr,..r.l,Q!� •,!}.w)' y. � ✓ •.+5 t f `�,I!S j'U, `�� ,1. .r )(, r �� I i tw l L ( 7',r•• !I• • ' l ♦, f ' {•� �+',4. ,�J,31 ♦�r�J�,�r� �i'r ill �},f.,'i 1. l ar il''t.:r�j, ,yt '. • � , ,,�: +:`.�;}•r::,?�';,;J /'b� �i`+ :,Slpnatur®o(Haulsr!}� r� �' .t'., x819 s .._..r .http;//wi�rw.mass gov/dep/,water,approva)s/t5forms,htm#Inspect C t5forrM.doa 093 J System Pumping Recard Page ! ' TOWN u� ��ux�i•I1 ,�r�'ch.�� 1. U 1't ��� 5YSTEN'l PO MPINU FLZC O .. AJ(') i p ........ �. ...Q0ANTITY PUMpC,L` Y�a„ >Vpuc .. "iA rvk15 rya xov'rI ovo>a CONOt'fIUN I'ul,.;. TV �'Ci� ry 4YY O h58 0A,Msa RO'4T3.: gXC 8rY6 3p1~1p .• L EitiCK.pc 1 q IZVN�n�'ti. �4I.CD CA KX Y®YU P�ooD�q A. � uNI �N!'� fx.�lNyy11XK,13U I't 1 1 f TOWN OF` NO$.TH ANDOVER SYSTEM PUMPING RECORD DATE , SYSTEM OWNER&ADDRESS SYSTEM LOCATION /V V A)o lJ(,-11 . Ma , DATE OF PUMI'lNQ / QUANTITY PUMPED CESSPOOL NO__j�: Y`ES SEPTIC TANK NO YES NATURE OF SERVICE;:,ROi TINE EMERGENCY ;a OBSERVATIONS; GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS ' FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY COMMENTS; CONTENTS TRANSFERRED To I TOWN OF NORTH ANDOVER i SYSTEM PUMPING RECORD DATE: °` i SYSTEM OWNER& ADDRESS SYSTEM LOCATION , 1 (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED /��'0 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: COMMENTS: CONTENTS TRANSFERRED TO: l/ /l�0.� / I f TOWN OF NORTH ANDOVER SYSTEM PUMPING I-ECO (ZD IEWUWNER &'AD DRESS — -- OF PUMNINC; O Z , QUANTITY PUNIPCD/ I ��PUOL NO> YES SEPTIC TANK NO f E; I URE OF SERVICE: ROUTINE ENII'RCEN("y -- " !:(tV �vTf 0N5. C OUD CONDITION FULL TU C'U ','C HEAVY CREASE L AFFLES IN ------ ROTS LEACHFIELD Its— " JAL K -- EXCESSIVE SOLIDS FLOODED ----n SOLIDS CARRYOVER O.�HER (EXPL,AIr,) - tiI FNTs I,�; TIZANSrEIZIZED TU Commonwealth of R as � h e +t ' City/Town of ~ ,� I)d~ e— Syste Pumping Record .� � Form 4 DEP has provided this form for use by |000| Boards of Health. Other forms may be uoed, 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 i4 days from the pumping date in accordance with 31OCN1R15.351. A~ Facility Information Important:When filling out forms 1. S y s ha L 7ct,1110,In, on the computer, 7 use only the tab key to move your xuu cursor'gonot use the return - key. CK [Town - State Zip Code VQ 2. System Owne r ` -------- Address(if different from location) City[Town State Zip Code � / Telephone Number � B. Pumping Record 1 Date 2 C>uenUtyPumped� � oe� ' ~~ ' � � Gallons 3. Type ofsystem: El Cesspool(s) Septic Tank El Tight Tank Fl Grease Trep ` F Other(describe): 4. Effluent Tee Filter El Yes El No |f yes, was it cleaned? El Yes F1 No 5. Condition of System: G. System Pumped By: Name ' Vehicle License Number vice Company 7. Location where contents were disposed: Stew art's Pre-treatment Pl t 20 So. Mill Bradford, Ma 01835 \ ` Signature ofHauler Date Signature of Receiving Facility Date t5fonn4dou`03/08 System Pumping Record`Pagm 1 of Commonwealth .�C�D7����MV����/u / w/ ��'f�/T f �� � � City/Town ��/ n���.����wo\yer o System Pumping Record Form 4 OEP has provided this form for use by local Boards of Health. Other forms may be uoed, but the information must be substantially the nemn 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 i th it within 14 days from the accordance with 310 CIVIR 15.351. Important: A. Facility Information When filling out /. System | �nnoon�e � computer, use only the tab key Address m move your No.Andover W10 01845 oumor-uonou usethe��m City/Town State Zip Code key. 2. System Owner: Name Address(if different from location) City/Town State Zip Code | � Telephone Number B. Pumping Record � 1. Date ofPumping 2 Quantity � oo� ' � ' ' � Gallons 3. Type ofsystem: El Cesspool(s) F-1 Septic Tank El Tight Tank El Grease Trap F] Other(describe): 4. Effluent Tee Filter present? El Yes El NV If yes, was it cleaned? 0 Yes El No 5. Condition of System: ne d B — | � Momo r - Vehicle License Number � Sbevvart's Septic Company 7. Location where contents were disposed: � SbeworCa Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature ufHauler Date Signature nf Receiving Facility Date t5hu,m4dno^03/06 System Pumping Record~Pago I of Commonwealth of Massachusetts � j City/Town of No Andover 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 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 145 (-U- M-n,e key to move your Address cursor-do not No Andover M 0 3 use the return City/Town Stat Zip,Code key. U, fT f i 2. System Owner: Name rehon Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: 'Date Gallons 3. Type of system: ❑ Cesspool(s) 1— Septic Tank ❑ Tight Tank F-1 Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Sy em: 6. System 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 Sipna'ture of aui6r Date .................. ",CW', Signature,of Re'6eiving Facility ........ Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 -Cbrimonwealth of Massachusetts r `�� ity/Town oaf r; -System Pumping Redded NOV 1, 3 2006 Form 4' I TOWN OF NORTH DER has provided this form for use by local Boards of Health. ��� Wj- rd must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1, System Location: 4 forms on the computer,use r only the tab key Address_ to move your � ✓ � /�,v/! r cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Name "1UA Address(if different from location) Cityrrown State ip Code Telephone Number B. Pumping Record /15' 1. Date of Pumping Date 2. Quantity Pumped: Gallons Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank -= ❑ Other(describe): 4, Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5, Condition of System: 6. Sy em Pumped By: �G Name Vehicle License Number 5� cd , . �WI �-, adlord) Ina Company 7, Location where contents were disposed: Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc*06109 System Pumping Record Page 1 of 1