HomeMy WebLinkAboutSeptic Pumping Slip - 64 BOSTON STREET 12/18/2015 Commonwealth of Massachusetts imEkJi
= _ City/Town of North Andover Ok:a[
--
Syst.em Pumping Record a� �lvE�� � �ltti �AND(JVE
Form 4 b , x,14;� r ,......�� I l e d
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 musabee submitted to
the local Board of Health or other approving authority within 14 days from the pumping,
accordance with 310 CMR 15.351.
A. Facility information
Important:When
Ming out forms 1• System Location:
on the computer,
B,:�)
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover Zip Code
use the return State
City!"fown
key.
2. System Owner:
I °
a Name
Q acm=y7^�' I I
� Address(if different from location)
State Zip Code
city own
Telephone Number
B. pumping Record
c" _( � 2. Quantity Pumped: Gallons
1. Date of Pumping Date
3. Type of system: F-1 Cesspool(s) E] Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No if.yes, was it clearied? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic ervice
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
System Pumping Record•Page 1
t5form4.doc•03/06
i
l
r ({µ�Jl
��d � A k7 t�lA r�F1'k<,r its
uS �
GI1t3ttS 1
fr,,i ' /�� � r C►�'THI.A IO VE '. MASS CHUS ` T
C urnp�n c r
,��
1
, 3;t1 ,L G.•, t rr r Vni , In l,t t a,..m.
DEP,,has provided�hls form for use by local Boards of Health, The Systoroi, i;iipir g Record must
be submitted to the local Board of Health or other approying autho fly, C
k Falciiity Information „
Ro �n� t I/ 1«\!
„ When,,lung out 1,. System Lora on, 1
forms on ':, .. ....
.;. ,�` CIE �� �
Cl
"camputer,use .I
only the tab key Address
to move your (�. ✓ ' " '
cu(sor do Prot ..
Cite the return QIWown State
r+ l `Y , 1, p Code
�Y x Y, rl'tY rt 21 System Owner, , ,.
.Name
Address(If different from location)
Clty/Towrt
state odd
t ar I
Te ephone Number
in Record
1�'r�, `t!K �ytil,y},li �r4 t� „,.. � •
Date'of Pumping ' Date 2. Quantity Pumped; -Gal
3, Type pf system, ❑ Cesspool(s) eptic Tank ❑ Tight Tank
®'Other(describe),
4r
Effluent Tee Fllte{present?.,❑ Yes J2 No If yes, was If cleaned? ❑ Yes ❑' No
„•, t r,. , ht 14�r.lid„�'•ir`q!�,''n. v♦`IpIQr.:, � ,r°'” ' .:,},
Condi�on of Sysm;'"
r r I
6 Sy Q Pumped y-
1:,,
Cj
T. t
Vehicle Ucen*e Number
�1ame . ri ya Y f
'W"
ttr •fir �n4°1rr"rr�yj�fy77+t,���'1 �I� oa<tt�5 t I
� t
tCom�
'�X Y„i�La(�1Fr J t�D�f'�,�tr Up ,t ,•, �
• /'r ny1 f/ art a�..iw dPtryk4+fir �yt.R��W� , �i,1w tJl y�rt,�rV'.{,' I;� �', ,
where contents Were dl;3posed;
,
�, '/r +3 a iA r�I �'r(r Fr7 �I'i 4rt ✓,r.,5., r 1� ,' 'F,� f t� �' ��f� �. ,
! �' +::`.t, SlgnatUrrioflau ;atd °,, F ..,.. .
Date
http/hnvw.mass.gov/dep,wafer/a pprovaJs/t6formsrhtm#lnspect
t5fOm14rdOC•t')8/03 ',,
System Pumping Record•Page t of r
1
r
1
1
1
TOWN C)l" r 4^d y`9 g fl A. Dg t r,"I
pp N gg p qqN yg I
DA F6 "-61
" S '. ..� 4✓ w
OF 111W l( III N(1: ire QM)AN'TL'N Y llf,) (-"1 13
CESSPOOL: J"10-
.� 1`l Plt�:,f�1' '�lia$'a�0e`1..^, iCG.7L1"1 N11"_...�,�'' 1�':k�/Npt1•C4s'T'1�lT::"`�'
GOOD("O"Nt:al`l°ION 1 1 JLL`1"O
R64,O S _ LEAC,."H Tl"aLI-) T f,lNBAC.K
SOLIT
CQMML?.N T'c�
03/02/1997 01:48 5083736611 STEWART/Ah DOVER PAGE 01
1
A/641
u r®
CL
)36 All mm BMW
®Ol A 47 Ruix#nW MV=
WMWI ll t /® r Mh 01835
e�
J 978-372--7473.
Plan cr
ax IMPOM PM 70M
or
? or
17 d
!3 C il-
` - ch
el
33c? � (/
/660
L
�/l
�
.�,_I
-20 bbo
6 ;�
Jb®c�
Lit 1 1614) c
„ .� rot road