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HomeMy WebLinkAboutSeptic Pumping Slip - 272 BRIDGES LANE 12/28/2015 Commonwealth of Massachusetts W City/Town of NORTH ANDOVER a System Pumping ecor Form 4 l 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, 2 use only the tab 72 BRIDGES LANE key to move your Address cursor-do not NORTH ANDOVER MA 01845 use the return City/Town State Zip Code key. tab 2. System Owner: LINDA HIBBS � Name Address(if different from location) �, C City/Town a e Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 3/31/15 2. Quantity Pumped: 1500 Date Gallons 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: GOOD CONDITION 6. System Pumped By: JAMES H CURRIER II H79 406 Name Vehicle License Number X SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD 3/31/15 Signatural6f Hauler Date Signature of Receiving Facility(or attach facility receipt) Date I t5form4.doc•11/12 System Pumping Record-Page 1 of 1 I f bill ri Commonwealth of Massachusetts rr City/Town a of . ANDOVER System Pumping Record �V q 1,'8 WW Form t DEP has provided this form for use by local Boards of Health. Other fort 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 Heaith 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 1. System Location: forms to the 272 BRIDGES LANE computer,use _- --___ -- --- only the tab key Address to move your NO. ANDOVER MA 01345 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: � ARTHUR HIBB — -------- -- Name Address(if different from location) City/Town State Zip Code —._... -.--._.-. —.... Telephhonon e Number B. Pumping Record 4/12/13 1500 1. Date of Pumping —Date Gal 2. Quantity Pumped: ----_lons__...-___— 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? [I Yes ® No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: JAMES H. CURRIER _ H79 406 _ Name Vehicle License Number J's SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD _..---....- _.. 4/12/13 Signature of ifauler Date - ........-_........._.-. — ................-..... _. -- Signature of Receiving Facility Date t5form4.doc•03/05 System Pumping Record- Page 1 of 1 i r RECEIVED Commonwealth Ith of Massachusetts w City/Town of NORTH ANDOVER jj.j�. 2� 1 Farm I HEA[.'r��DEPAR'rMEI�� M s f DEP has provided this form for use by local Boards of Health. Other forms may be used, but the i 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 1. System Location: forms the computer,use 272 BRIDGES LANE only the tab key Address to move your NORTH ANDOVER MA 01845 cursor-do not city/Town State Zip Code use the return key. 2 System Owner: 110 rab LINDA HIBBS Name enun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping ecor 1. Date of Pumping oa?e13 2. Quantity Pumped: 1000s 3. Type of system: ❑ Cesspool(s) 5d Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: GOOD CONDITION 6. System Pumped By: JAMES H. CURRIER H79 406 Name Vehicle License Number J's SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD 7/7/13 Signatu of Hauler Date Signature of Receiving Facility Date t5fomn4.doc•03/06 System Pumping Record•Page 1 of 1 i 1 orTimonwealth of Massachusetts City/Town of NO. ANDOVER System i r Record Farm 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 P omitted to the local Board of Health or other approving authority. A. Fixity Information � �� � RTM Important: When filling out 1. System Location: -rOW p N091'H AN00V forms on the LT DEPA RTMENT computer,use 272 BRIDGES LANE only the tab key Address to move your NO. ANDOVER MA 01845 cursor-do not use the return City/Town State Zip Code key. 2. System Owner: ARTHUR� UR HIBBS _ _ Name - - ------._ e un Address(if different from location) -- City/Town State Zip Code Telephone Number B. -------- --- Pumping scar 11/1/11 1500 1. Date of Pumping Da te - 2. Quantity Pumped: --Gallons- ------- Da 3. Type of system: F] Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): - _ 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: . System Pumped By: James H. Currier H79 406 Name Vehicle License Number J's Septic& Drain Cornpany 7. Location where contents were disposed: OLSD / ..Z' 11/1/11 Signature of Hauler Date t5fonM.doc•06/03 System Pumping Record•Page 1 of 1 ANT RCH US ' F?6Ald �. _. � � 10,� Y 0 E ha; ptovld©d ;W; to"" r p. 50 1 wvn`HQC SO G'10 I0, 6, a tlU RCtl���y fti'` ZOOS., cf 9 .11 '�� , ;•���>�, r2.� X3 or Owner 0/OVflrrnl icvn locnucr rr 0 C. 0 Q ,.Pumping R�Gord Oa,� P�mpinq �F tv . � Tyra 0� by�lam; � ��ss�oo'fs1 �' arl; T�� �, r,y�, ,•a�f - (dwnho): a Etflu�n� Tee FII49 r asn� i. 1 V/.'�•' i ,��� j LM �V�9-� od 0id 7 !OG8 n �'n ( C 8 6 GOrll8nl5 ware C,9 .S8 2 h� - M8YJ Po.r/dUPWO1000 �rova)s/Iblorm9 n n Commonwealth of Massachusetts ? ti City/Town of NORTH A NDOVER MASSA �HUS9'TT System Pumping Record Form 4 /5,U a 0 00 DEP has provided this form for use by local Boards of Health. T �� '`� f'' ��' urns f,n" " �i , phi P p 9 I�eco,d mu ' be submitted to the local Board of Health or other approving aut ority, A. Facility Information Important: When filling out 1. System Location: forms on the ,�,� computer, use ,,, A'��z, only the tab key Address .. �' to move your cursor-do not Clt /Town ------'-'—_ --° — use the return y State Zip Code key, 2. System Owner: Name _ .------— Address(if different from location) City/Town .._ .-------------- State Zip Code Telephone Number B. Pumping Record 1 2. Quantity Pumped: Date •. . Date of Pumping - -� - � - ��- Gallons Type of system: ❑ Cesspool(s) _.Se-ptic Tank El Tight Tank ❑ Other (describe): 4, Effluent Tee Filter present? ❑ Yes,, If yes, was it cleaned? ❑ Yes 5. Condition of System: 6. Sy ern Pumped By; me Vehicle License Number Company _ 7. Location where contents were disposed: Si ature of jau4 _.__..__..._ __._._.. 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