HomeMy WebLinkAboutSeptic Pumping Slip - 80 WINDKIST FARM ROAD 12/15/2015 Commonwealth of Massachusetts
City/Town of EC!E!V'ED
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other for 'WRTH ANDOVER
information must be substantially the same as that provided here. BeforL% I c eci:wi h your
local Board of Health tQ 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
1. System Location: Left side of house, Right side of house�LeftjcQnLpf house�-Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address
City/Town State Zip Code
2. System Owner
Name
Address(if different from location)
Telephone Number
B. Pumping Record
' Date of Pumping Date ^' Quantity Pumped: Gallons
3. Type ofsystem: [] Tank [l Tight Tank
L] Other(describe):
4. Effluent Tee Filter present? F] Yes D"N |f yes, was dcleaned? F1 Yes E] No
5. Condition
S. System Pumped By:
Nai| Batemon F5821 |
Name Vehicle License Number
/
Bateson EnterprisBs Inc
Company
7 Louot
G.L.S.D LLowell WpM Water.
Signature ~' D"=
' (
t5mnn4doo06/03 System Pumping Record`Page 1of1
Commonwealth of Massachusetts
i City/Town of
w� System Pumping Record
Form
DEP has provided this form for use by local Boards of Health. Other f rms ma be
information must be substantially the same as that provided here. B ithl C):p'l ,qhi dk� 'th your 1
local Board of Health to determine the form they use. The System Pu ping'Record USt°lj#'submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
p
p cation:
forms o filling ouk 1. System t k�
only the tab computer,use y
cumoVedonot
y Address
use the return City/Town State Zip Code
key. f
2. System Owner:
VQ Name
' Address(if different from location)
City/Town State ,. Zip Code
" .m.
Telephone Number
B. Pumping cor
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspooi(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? ~
p El Yes allo If yes,was it cleaned. E] Yes ❑ No
5. Condition of System: •..
x.
6. System tamped By
Name °°°- Vehicle License Number
r.,.
Company
7. were d' sed:
Location re contents w�
Signato of a er Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECEIVED
7]*
City/Town of No Andover
System Pumping Record JUN 10 20,13
Form 4 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Oth;r`f_o_rms 'm-ay"'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 1, System Location:
on the computer,
use only the tab to waj- ki's
key to move your Address
cursor-do not No andover Ma
use the return CityfTown State Zip Code
key,
2. System Owner:
Q I
flo /1 I�6_s
Name
ieum
Address(if different from location)
City/Town State Zip Code
Telephone N amber
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: F-1 Cesspool(s) 2rSeptic Tank r_1 Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes F-1 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewbrt's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
1
Sign u�re of Hauler Date
a ..........
ii An ' e of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1