HomeMy WebLinkAboutSeptic Pumping Slip - 45 BOSTON STREET 12/18/2015 &\ Commonwealth of Massachusetts
Cl /To wn of North Andover
ty
ecord
S s e m Pumping
t R
Form 4
wy DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
provided here. Before using this f0rm,.check with your
information must be substantially the same as that pro pumping Record mustIbe submitted-LO
local Board of Health to determine the form they use. The System
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CM R 15.351.
CE IV ED
A. Facility information RE
Important;When U I 21,115
1 System Location:
J
filling out forms
on the computer,
use only the tab i L I i L_j I-j
key to move your Address Ma 01886
cursor-do not North Andover State zip Code
use the return Cit y[Town
key.
2. System Owner.
Name
Q rcm= n� I i
Address(if different from location)
-----------
State Zip Code
Cityrrown
TOephone Number -------
B. Pumping Record
2, Quantity Pumped: G5,11MIs
1. Date of Pumping Date
❑ Grease Trap
3. Type of system: E] Cesspool(s) 5/Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No -if yes,was it cleaned? E] Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
ame
Stewaff s ice
rt�
Com
ocation where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Date
Signature of Hauler
Signature of Receiving Facility ate
System Pumping Record-page
t5lorm4.doc-03/06
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l)EP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving auth rityl
,... 2007
X Facility Information
r rW
filling out 9,. System L cation
foima on the ' ..�� u
.. :.
.computer,use ..' � '
only the tab key Address
to move yob i ;I; CI /Town
: cursor do of � .w,�
Use the retum' tY State Zip
y Code
key 2,
System ®weer,
7
Address Of different from location) —
City
State
, a
" p
Telephone Number
f : PUmping Rdcord
r. ,rim { ' 4 , tx :I t :Ir.• ,.„.�'�
1 Date'of Pumping Date./ _. 2 Quantity Pumped; --
Gallons
3 TYpe of system, ❑
Cesspool(s) Se tic Tank
p ❑ Tight Tank
❑ ®ther(describe);
4 Effluent Tee Filter present?.❑'Yes o' If yes, was If cleaned? Ye ,
❑ o
>` - 51` ;Corldltlon of SystS(Qiml'' J .J
i
TCM
Sy em Pumped B '
S
Vehicle Llcen*e Number
71 Location where contents yvere disposed;
ti
r ,�,', , �,� �stgnsture Of Hauler;,,are. Date
httpJMww mass gov/dep/water/apprQvals/t5forms,htm#lnspect
t5fomA.doc-08/03
System Pumping Record•Page 1 of i
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
k (example: left front of house)
C
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 LE ACIMELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANS FE RRED TO: