HomeMy WebLinkAboutSeptic Pumping Slip - 234 BRIDGES LANE 12/28/2015 r
Commonwealth of Massachusetts � 5 1
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City/Town of North Andover
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System Pumping Record
Form
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 —_—_—._--_--.—.
—--
key to move your Address 01845
cursor-do not North Andover Ma —.-----.--
--------
use the return ------_-- -------_.—_---._ State Zip Code
key. City/Town
2. System Owner:
Name
Address if different from location)
---—.—___—._—..—..--
City/Town
State — --- Zip Code
Telephone Number
B. Pumping Record �-�
/I — 2. Quantity Pumped: Gallo
1. Date of Pumping pate ---_—,c-
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -----------------------__------
4. Effluent Tee Filter present? ❑ Yes 0"`N0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. qystem Pumped !:
Vehicle License Number
ame
Stewart's Septic Service ----_--- _
Company
7. Location where contents were disposed:
S ewartIs Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 — — —__ ----
ignature of uler ., Date
Signature.sfteceiving Facility Date
System Pumping Record•Page 1 of 1
t5form4.doc•03/06
1
TOWN OF NORTH ANDOVER
SYSTEM PING RECORD
DATE:
SYSTEM OWNER,,& ADDRESS SYSTEM LOCATION
(example: left front of house)
6 4
DATE OF PUMPING: QUANTITY PUMPED /J"�� GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES'Z
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:
COMMENTS: °/�
CONTENTS TRANSFERRED TO:
iT: � tiZrti` '' ,... : ,-X :, , 11 �rg,o' 'xr✓ ,�br,,! wf 1 Y ��*Y ��'D���y����'��j��i�yr��' �,�9v, S `' ` '' a �a 1 9
VhUs"
t � OR; ND0 ER ' MASSADHtJSE
"TTS
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acrd '.'
n, .e #9rFFttFOI� TI �+e J'i 'tJ 1t�.i�iJy� 1\H { 1
'y, Niel , ??t}�htlj.�9•`� .,�, '.• t ,'(.f,• ,':"' � � � .
has provided this form for use by local Boards of Health. The System Pumping Record must
be>$ubmltted to th @.local'Board of Wealth or other approving authority.
A. Facili Information ,
. tY
-,;*-Jrnportant ,
1 em Location
;s,?..yvhen dung out � Y r
syst vie
em
use
Computer,
only the tab key Addresa
to move your ,�° r.f?L•• P
cursor do not State CltyRown p Code
ZI
use the rotum 1
2' System Owner, � ..._., .
1' y Name �` r,� �rr , �rq/ aF..0 .,
y
Address(if different from location)
ode
citytTown
y
Telephone Number
.
Pumping Rscord "
"J":
a �� 1' Date of Pumping Date 2, Quantity Pumped: ions
Cess o'ol s beptic Tank Tight Tank of system ❑ p O
M .Other(describe);
4, Effluent Tea Filter present? .❑ Yes Nb' If yes, was it cleaned? Yes ❑ Na
S Condi�on of yst�m;`
• I�rr I Y:..h Y,,J� ti 1 ea, ��Jr.�,, �
Sy em Pumped sy�
Vehicle Llcenae Number
;.fit 5� 9n�".°1{{%�rC�rJrlr•�r,�fL����I�.rF •%1� I�<r4 � Vt.�-+k+� I V�Vf � I • ""
'SdV r ��. 'Compan i �Jyw
r t. � N7Tn�y loi$l+P}��yw,� 't� ,t� � ryJ•�t��, t.,;�. a, .. ,
'Location where contentt Wer@ dl;3posed:
Ma
�P°„�"�y���.
r P
t , � , St�hatur4ofHaulor ,,;,, �. Date
httpiwww.'mas's.gov/dap%water/approvels/t5forms,htm#inspect
t5fom14.doc+06/03 System Pumping Record-Page 1 of t
t
i
TO" OF NORTH ANDOVER
SYSTEM PUMPING RECORD
1
s
-. "1'EM S TE ADDRESS SYSTEM LOCATION
�1 OWNER & AllD
(example; left front of house)
4 C-1 ff
U:\1'E OF PUMPING: ? e QUANTITY PUMPED 'GALLU �S ,
I'UUL: NO "° YES SEPTIC TANK. NO YES
VATURE OF SERVICE: ROUTINE EMERGENCY
(ffl,�FRVATIONS, LL TO CUVEI�
GOOD CONDITION FU
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER �JHFR (EXPLAIN)
PUMPED ELY:
(,'umlyIENTS:
U I'S 'I'(ZANSFEIZRED TO:
I
wu
TOWN O� NORTH. ANDOVT R
SYSTE ` PUMPTNQ REC�ORT) C�vup ��� �n���A�"�D d
s C oEPA� t� ....
DA t
SYSTEM OWNS & ADDRESS SYSTEM LOCATICaN
DATE OF PtJMPiNU._.... ._ . ... ..__...,._QI.IAN'rTTY PUMPED:..._:..
t'I:SSI'WL: NO YES Sdptic lank: NU, YElS
NA WKE OF SERVICE: KOU'CINE.-K„ _. WNRUEN('1'
0I3SERV A'rIC3NS:
400D CONDITION //FuLLTO
COVER
HEAVY GREASE _.�_ BAFFLES IN PLAC L
ROOTS _ LEACHFIELD RUNBACK
BXCBSSIVE SOLIDS .._.___ FLOODED
SOLID CAKR,{Y/O,V`ER..,....,.....OTHER EXPLAIN .
5yrtam Pumped by .....�,.,/�'C.(..�1..�./..` ......S.:>el .1/ ..5 e/"^4)
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FOWNI A m SYSTEM PL':.NI.L'L\G RECORD
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Commonwealth of Massachusetts
Massachusetts
yslcrrt t�rrt�ri±rt e�cvr°
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Date of Pumping °° Quantity Pumped: t
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Cesspool: N,o , N'es entir TgnI-- t.tr% Yes
System Pumped by, _ License #:
Contents transferred to:
Date _ Inspector
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