HomeMy WebLinkAboutSeptic Pumping Slip - 51 BANNAN DRIVE 12/18/2015 REC Commonwealth f clJ . I
iyrf wn Andover .. I
SYstem Pumping TOWN OF O RI`i i ANDOVER
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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 1 "
key to move your Address t � -
cursor-do not
use the return No Andover
key. Cityrrown Ma
State Zip Code
2. System Owner:
Name
Address Or different from location)
CityFrown
Skate Zip Code
B.
in
Telephone Number
r
1. Date of Pumping Date ,. ' 2. Quantity Pumped: _ )
Gallons
3. Type of system: Cesspool(s) ❑ Septic Tank
❑ Tight Tank ® Grease Trap
❑ Other(describe):
r
4. Effluent Tee Filter present? ® Yes ® No if yes, was it cleaned?
® Yes p No
5. Condition of System:
l C c'
6. System Pumped By:
Name .
Stewart's Septic Service Vehicle License Number
Company
7. Location where contents were disposed:
SteWbirt's Pr -treatment Plant 20 So. Mill Bradford Ma 01335
Si __. Date
Signature o Sere g Facility Date
t5form4.doc•03/06
System Pumping Record d Page 9 of 1
..........
Commonwealth of Massachusetts
City/Town of North Andover N�J�"
System i r
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the J
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 _ + ! 14��❑ i e
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
mMm
_ ........__.....--
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ecord
P� Y
1. Date of Pumping /� o !--J 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 o. Mill Bradford, Ma 01835
Q. s' ure of Haule Date /0/"q
Signature of eceiving Facility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
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has provided this form for use by local Boards of Health. The System Pumping Record must
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be subin(4ed to the.local'Board of Health or other approving authority,
A. Facility Inforri
.kn Lion
�rrMen'fuung out 1 System Locaflon;' , 4
. r:•.: ter�use - S
only the tab key Address
to move your
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r System Owner, ; r
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Clty/Town ,I
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/' �� �J umpl�g Re{ cord ♦„•,I.rY .
td. j�,�ttitf�r..f! Jr ju r.a9,r}�1Ii5Y�'1'�I.II' /L
> ' 1 '. Dat�'of Pumpinq n Pumped:
Oats 2 'Qua tJ ty
Gallons
Typ®pf system:" ❑ Cesspool(s) '� ptic Tank ❑ Tight Tank
J®they(descr(be)r
I. Y Effluent T®e Fll,t®�•presen,t7 ❑ Yes ' o If yes, was It cleaned? ❑
❑ Yes No
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
u.A TF: 6,2 1441e,149a
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front ro f house)
4JC' he
UA`I'E OF PUMPING: �. QUANTITY PUMPED GALLONS
C f'SSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
U 13SERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
5Y`:`I'EM PUMPED BY: /
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CU.MMENTS:
CO' TE'N'1"S 'T'RANSFERRED TO: