HomeMy WebLinkAboutSeptic Pumping Slip - 32 BRIDGES LANE 1/5/2016 -C-N Commonwealth of Massachusetts RECEIVED
City/Town of NORTH ANDOVER 10 014
s o System Pumping Record
'I'UNN OFNORTH AND(M•c'Iw
Form 4 E L]. l�D PARTME
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: r
on the computer,use only the tab `' Nd `1
key to move your Address
cursor-do not NORTH ANDOVER Ma
use the return City/Town State Zip Code
key.
2. System Owner:
r�
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ 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. Condition of System: (( 0,
6. System Pumped.By:---2
..Name wry"` Vehicle License Number
frHN Stewart's Septic Service
. -. _ ompan
y.-.--Locatian.,wher,..contents were disposed: -
ewt
w. . Pre-#reatm�nfilnt, 20 WSi: Mill-.Bradford, Ma 01835
t ar s
Signature of Hauler Date
Signature of Receiving Facility - ae
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of No.Andover
System umpin Record
Form 4
M
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 1. System Location:
forms the
computer,use l�-t-
only the tab key Address ,
to move your No Andover Ma
cursor-do not City/Town State Zip Code
use the return °:❑
key. 2. System Owner: try ,.
rF. yl r'
Name � �: w �
Address(if different from location) p-pt At Tp,pY . f�pry
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ti � r 2. Quantity Pumped: f
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Y No
5. Condition of System:
6. System P ped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill,Bradford, Ma 01835
Signat a of I r Date
Signat V f Re iving Facility Da
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Co`mmonw�aft pf IVlass chusetts
MASSA�HUSEI'T'S
ity/Town�'Q ,'NORTH AN D®VR,
System PumipIng Regard
Opim"4
DER has provided this form for use by local Boards of Health. Th ystettt Pumping Reeor must
be submitted to the local Board of Health or other approving auth rity t �� �.�n�� i�,�,�:�
A. Facility EC 6 2006
.:-Important:
,_•,VVherf filling out 1. System Location: i �� i [5i � AN,
T('AN �(ru- 6 i ,i I Iii aer[ n
fortes on the <� /
computer,use
only the tab key Address
to move your
cursor-do not State Zip Code
use the return City/Town
key..
2. System Owner:
Name
rw„ Address(if different from location)
City/Town State rzip Code
Telephone Number
,,. B. Pumping Record r
Da Pumping 2. Quantity Pumped: 6aiions�
'0 p Date
3. 'Type of system: ❑ Cesspool(s) eeptic Tank ❑ Tight Tank
Other(describe):
4 Tee Filter present? ❑ Yes No' If yes, was it cleaned? ❑ Yes o
dition of System:'
6. Sy em Pumped,By:
Name- Vehicle License Number
Company
7: . Location where contents were disposed:
G�(�f
l
Signature of Hauler Date
http://www.mass.gov/dep/water/cipprovals/t5forms,htm#inspect
t5form4,doc+06/03 System Pumping Record•Page 1 of i
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TOWN OF NORTH'A OVER
SYSTEM P11kPING COIF
►)A'!'rt.
->f'STEM OWNER & ADDRESS , SYSTEM LOCATION
(example: left front of house)
,r
e Y !?
UATE OF PUMPING.- 1 QUANTITY PUMPED , rc,. QALL0;1,
C ESSI'UOL: NO `5<"" YES SEPTIC TANX: NO YES "
NATURE OF SERVICE; ROUTINE, � �.�. EMERGENCY
ullar;RVAT1ONS:,
GOOD CONDITION FULL TO COYER
HEAVY GREASE BAFFLES IN PLACE
ROOTS I LEACHFIELD RUNDA+C:K..,.
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER �,DWfiFR (EXPLAJN)
7
*1'S'I'L,1 PUMPED BY;
.i
c.Valk)CNTS:
!'RA IqSPC, It RE 0 TO: