HomeMy WebLinkAboutSeptic Pumping Slip - 79 BEAVER BROOK ROAD 12/18/2015 Commonwealth of Massachusetts
w p City/Town of NORTH ANDOVER , �°�.�� ..� p
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System Pumping Record � Vvir ���„.ohs ��� i��aVE��
Form i� �A x� � � � �? ��FiENr
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, g°
use only the tab 4 � ��a�° �1 �
key to move your Address
cursor-do not NORTH ANDOVER Ma
use the return City/Town State Zip Code
key.
rQ
2. System Owner:
Name
I
�eRm
Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping / l� 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:
6. System Pumped By:
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
uler Date
Signature of Receiving Facility Date
t5form4.doc-03106 System Pumping Record•Page 1 of 1
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�arrtnnon �l h: �f �J1a sachusettS . I
q itylT�wri'f NtJRTH�A�OOVER MASS
y,Steles Pumiping Rec®Ird
Form"4 . NOV b6
DER has provided this form for use by local Boards of Health. Tkf cord must
"
be submitted to the local'Board of Health or other approving rl��EPA P IENT
A. Facility Inform,atioin
Imp
®rtant:
.,When filling out 1 System Location: .
forms on the
computer,use" ,,. ��_. �� / (.1�,��.� �. ���
only the tab key Address
to move your Wo ° (,")"e
cursor-do not Cityfrown State Zip Code
use the return
key,:- ,:.•s
2. System Owner:
Name '
"0J Address(If different from location)
Cityfrown t e Zi Code
Telephone Number
B. Pumping Record
1' Date"of Pumping Date 2, Quantity Pumped: canons
Type of system: . ❑ Cesspool(s) eptic 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.
G
Name Vehicle License Number
• , . ,' �: �, j1�JCl..t!,Q,, f, •FOrC�� l'rlG?
Company
7. . Location where contents,were disposed:
/b/xAt1,q
Signature of Hauler . Date
http://www.mass.gov/dep/water/approvals/t6forms•htm#inspect
•
t5fomy4.doc-06/03 System Pumping Record•Page 1 of 1
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TOWN OF`NQ$TH ANDOVER
SYSTEM PUMPING RECORD `
DATE ,A Iq
SYSTEM OWNER&ADDRESS SYSTEM LOCATION ,
,'q t �� � � , ► .a
A
DATE of PUMPIrr QUANTITY PUMPEp
f
CESSPOOL NO VYES�_ SEPTIC TANK NO YES
NATURE OF SERVICB;;,RQl7TINE ' "` EMERGENCY
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