HomeMy WebLinkAboutSeptic Pumping Slip - 165 BOSTON STREET 12/18/2015 i
Commonwealth of Massachusetts t
city/Town of "
y t�err� Pumping Reeer-d NORTH ANDOVER
a
Form 4 r 1 tthe DEP has provided this form local Boards
that .sprovided here, Befog e us ny th s form b heck with your
information must be substantially lly ly the same ° tted
' �t
they use.The System Pumping
ecor �,
local Board of Health to determine the form � ]� ]
the local Board of Health or other approving authority within 14 days from th pu g
accordance with 310 CMR 15.351. « eiew r
A. Facility Information TOWP4 OF P4WZIR4 ANDfflVER
RIE A i��
Important: 1 System Location:
When filling out Y
forms on the - ___ �
computer,use – –
only the tab key Address
to move your r 1.1 1r4 r c�u°Li" ° Slate Zip Code
cursor-do not -ity/To
use the return
City/Town
key. 2 System Owner:
Nam
�,o Address(if diKerent iro��location)
Sta Zip Code
-- —----
te
City/Town
Telephone Number —.
B. Pumping Record
2. Quantity Pumped: canons
1. Date of Pumping Date
Tank [] Grease Trap
3. Type of system: ❑ Cesspool(s) .,,Septic.Tank ❑ Tight 9 ,
❑ Other(describe): -----
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
------ - Vehicle License Number
Name
Company
7. Location where contents were disposed:
Signature of Hauler � Date
_-
_ _ .. ._
Signature of Receiving_ —Faci._lity - to
System Pumping Record•Page I of i
i5form4.doc-03106
i
wW NVN 1 wlLl�✓rvA' 'PuiAll%
� Commonwealth of Massachusetts RECEIVE
City/Town of i I "i
System Pumping Record NORTH AND V
TOWN Or iw1 R"fl t ANDOVER
Form 4 14EAL A D I')AFT f NIEN T
DEP has provided this form for use by local Boards of Health. Other forms may be used but tie . ,
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:
1 System Location:
When filling out Y
forms on the
computer,use _. �- -- C J1�- --------
only the tab key Address
to move our --- _ _ -- -
y - - _ _ _--------- -at
cursor-do not State Zip Code
CitylTown
use the return
key. 2. System Owner:
Nam —
e
Address(if different from location)
Zip Code
Cit [Town � --
Telephone Number
B. Pumping Record
/c i - ---
1. Date of Pumping Date — 2• Quantity Pumped: aeons
3. Type of system: E] Cesspool(s) 0 eptic Tank El Tight Tank ❑ Grease Trap
❑ Other(describe): ------------._—_.._— __.------ -—------- --—
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No
5. Condition of System:
6. System Pumped By: _.
Vehicle License Number
Name
Company
7. Location where contents were disposed:
—:—_— --- _--- Date
Signature of Hauler
Signature of Receiving Facility Date
System Pumping Record•Page 1 of 1
t5form4.doc•03106
Commonwealth of Massachusetts
TS
City/Town of NORTH ANDOVER MASS A GNUS T �
- h J
- - System Pumping Record p ECF` 'E D
Form 4 F.
DEP has provided this form for use by local Boards of Hea th. The System pumping ecord must
be submitted to the local Board of Health or other approvi gfa)1,Aho0W(�RH,q ANDOVER til �i°V.4.i
A. Facility Information
Important;
When fining out 1. System Location:
forms on the • - "y
computer,use
only the tab key Add �10 move your cursor-do no! State Zip Code
use the return City/Tow
key(. 2. System Owner:
—
Name
Address(if different from location)
State Zip Code
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe): —
4. Effluent Tee Filter present? ❑ Yes [01'No If yes, was it cleaned? ❑ Yes ❑ No
5, Condition of System:
Good-
6, Systezp'0 ed By:
ry C:�I��(�, � ctrl�
Na e Vehicle License Numb r
Company
7. Location where contents were disposed:
Signalure of Hauler Date "ry
httpWwww.mass.gov/dep/water/approvals/t5forms.htm#inspect
system Pumping Record Page 1 of 1
t5form4 doc•06/03
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSAI',%H USETTS
System Pumping Record
0 Form 4
DEP has provided this form for use by local Boards of Health. hp.$ysterti_Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1 System Location:
forms on the
computer,use '5; P)f L6
only the tab key Address
y
to move our -I N V-' I "ter
L
cursor-do not
use the return Cityrrown State Zip Code
key.
2. System Owner:
L KI
Name
Address(if different from location)
City/Town State Zip Code
--
Telephone Nu��b—er-
B. Pumping Record
I
1. Date of Pumping 2. Quantity Pumped: 0
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
r-1 Other(describe):
4. Effluent Tee Filter present? El Yes R",
No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
x
zz/0
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
7J♦U+ OF NOR'T'HANDOVER.
SYSTEM PUKPING CORD
vr .I'EM OWNER & ADDRESS SYSTEM LOCATION —
V. �� rr � � .4� (�z m p I c Icf'( front of housr) .
f .a
f
U; I GrU'F PVM!'IN.C; ' QUANTITY PUMPQD �v
C.rir:.>.vooI.;`No YES SEPTIC TANK: NO
-7 YES
,
N..\TUBE OF SERVICE; � ROUTINE. EMERCEN '
(�IJSRRYATIONS,
"000D`CUNU Jill ON" FULL TU C0YEIt.
`FI '.AY Y CREASC BAFFLES IN I'I,ACI
ROOTS LEACHFIELD RUNDACK.r,
C. XCESSI-YE SOLIDS FLOODED`
50LIU,5' CARIiYOYER 14rD HER (EXPLAM)
>>' i 1 L"Mr PUM
.I
CUr1'IrM P,,NTS;
r
� U.�"I'I;�!�,"I'S, fi'� ��N�sr�IZ li�l✓'a fr'u, � •
ps �If
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
r
DATE: 0 '(
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
vet
DATE OF PUMPING: QUANTITY PUMPED 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:
4 .. r.
COMMENTS:
7
CONTENTS TRANSFERRED TO:
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