HomeMy WebLinkAboutSeptic Pumping Slip - 225 BRIDGES LANE 12/28/2015 -\
Commonwealth of MssachuottS" s
City/Town of North Andover
System P�� ink Record ���ge �� � �& u
4,
u
r �Farm EF
Z
gym.. e used, but the
DEP has provided this form far use by local Boards provided deed here. Before using this form, check with your
information must be substantially the same as that p Record must be submitted to
local Board of Health to determine the form they use. The Systempumping date in
the local Board of Health or other approvin authority within 14 days from the pumping
accordance with 310 CMR 15.351.
A. Facility information
Important:When
filling out forms 1• System Location:
on the computer,
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover State Zip Code
use the return City/Town
key.
2. System Owner:
a Name
Address(if different from location)
State 2%;- Zip Code
City/Town
Telephone Number
B. PUmping Record
2. Quantity Pumped: Cations
1. Date of Pumping Dat
e tic Tank Tight Tank ❑ Grease Trap
❑ 9
3. Type of system: ❑ Cesspool(s) p
❑ Other (describe):
If. es, was it cleaned? ❑ Yes ❑ No
4. Effluent Tee Filter present? ❑ Yes No Y
5. Condition of System:
6. Syste Pumped By: ,
� Vehicle License7 Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Date'
Pat f auler
ignature of Receiving Facility
Date
System Pumping Record•Page 1 0
t5form4.doc-03/06
Commonwealth Of Massachusetts
u City/Town Of NORTH ANDOVER
a System Pumping r
Form 4
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 225 BRI[7OES LANE
key to move your Address
cursor-do not NO ANDOVER MA
use the return _------- — - — _—__ ___- _-- --- ------
key, City/Town State Zip Code
2, System Owner:
KITABJIAN,
Name -..— -- ------ -------
Address(if different from location)
City/Town State Zip Code
i
Telephone Number
B. Pumping Record
1. Date of Pumping /- - G
2. Quantity Pumped: --
Date Ilons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank [l Grease Trap
Other(describe):
i
4. Effluent Tee Filter present? E] Yes 4No If yes, was it cleaned? [l Yes n No
5. Cond'ti l- of?ystei
6. System Pymp
Name Vehicle License Number
Stewart's Septic ;service
Company
7. Location where contents were disposed:
Stewart's treatment Plant, 26 So, Mill Bradford, Ma 01835
Signaturec�fiFlaul� Date
Signature Receiving Facility- C7
e of Reo y ate
t5form4.doc•03/06 System Pumping Record n Page 1 of 1
Commonwealth o| Massachusetts �
City/Town of North Andover
Sy~~~~-^^^ Pumping Record
�
Form 4 TOWN OF NORTH ANDOVER �
.�. li i
DEP has provided this form for use by local Boards of Health. Other forms ma 15e usR", r
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 CIVIR 15.351.
A Facility information
Important:
1
Wh���gm� . o
forms onthe
computer, use
only the tab key pmomso
to move your N d Ma 01845
mumnr'donm ' ^' -'-�Qtyrr � Zip Code
own State
use the return
key. 2. System Owner: _
v 'go /--,\I
Name *
Address(if different from location)
G�� Zip Code
City/TCity/Town yown
Telephone Number
B. Pumping Record 600
2. Quantity Pumped: -6-allons
1. Date of Pumping Date
3. Type ofsystem: Fj Cesspool(s) 2~�*epUuTank Tight Tank Grease Trap
F1 Other(describe):
4. Effluent Tee Filter present? F:1 Yee Fj No |f yes, was itcleaned? Yen |l No
-. Condition System:
C� C-Ond.
G. d B
a Vehicle License Number
NamWe
Stewart's Septic Service
Company
7. Location where contents were disposed:
Plant, �0 S K8i|| Bradford, Ma 01835 Date
Date --
System Pumping Record^Page 1 of
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" <DER has provided this formrfor usa by local Boards of Health, T e- . Pumping Recor must
be submItt®d to the local Board of Health or other a roving aut or W,E
. n.
it a 7F w fi ��
A Facility information .
k,,,H/tien filun�out 1'. System Wcatlon
w fcitjns.on the'. > !1 ✓' �f _i'C
•computer,use + l
only the tab key Address
to move your L
cursor do not City/Town State Zip Code
uss the return
Z;� � '
! i
Name r:
s'
i s ; Address Af different from location) ,
Clty/Town $tat Zip Code
Telephone Number
'f . Pumping Regord
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;`J. ate,of Pumpina ':'r oato 2, 4uantlty Pumped; Gallons
• .
3, Type of system, ❑ Cesspool(s) eptic Tank ❑ Tight Tank
®' Other(desoribe),
4, Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes o
` 6; Condltlon of Sysf�m.`
Sy e�,m Purnped By '
ame.l,� ,ri ;ly,, }51";✓W ,rt Vehicle Ucenae Number
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ha
$ nature of HpUi®r yi/.,y t l ,';,....�•,.. Date
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t5fotm4 doC't}6/03 : System Pumping Record -Page i of i
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TOWN OF NO TM ANDOVE P,
SYSTEM PU PING RECOFZD
UA t'k
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
DATE OF P[IMPtNC?: _...-QUANTITY PUMPED: /f�.
_.
CLZ5SP(X)L: NO YES- Supdc Tank: NO YE,
NA rURE OF SERVICE,: Roo-rINE..,k_- EME.ROENC.'Y
01:3SERVATIONS:
0001)CONDITION FULL TO COVER
HEAVY 4itPASE _ BAFFLES IN Pi.A(:l•.
ROOTS LBACMELD RUNBACK
BXCUSIVE SOLIDS _ FLOODED �
SOLID CARRYOVER"_.___OTHER EXPLAIN
5yrtvm Rumpod by �G�J••• ..._. �o. ...4-?�!/"U/CLJ
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: i
SYSTEM OW ER &ADDRESS SYSTEM LOCATION
(example: left front of house)
K (A Ice)
DATE OF PUMPING: q-,�-,&j 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: ' tom °i
COMMENTS:
CONTENTS TRANSFERRED TO: ,m.