HomeMy WebLinkAboutSeptic Pumping Slip - 89 BRIDGES LANE 1/6/2016 RE
Commonwealth of Massachusetts
7RE
o Cityjwn of ® Andov r T y te lT �� r VVR
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 1 ^� "°
key to move your Address
cursor-do not No andover Ma
use the return City/Town key. Y State Zip Code
2. System Owner:
Name
rstrm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date.._—Z? 2. Quantity Pumped: G Ip s
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:
6. Sy ed By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Ste\Ort's Pre-treatment Plant, 20 So. Mill Bradford Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
®m ®rw�alth of Massachusetts
" itY, own of N `TH AN DOVE R7MA
MASS
C
stem' '' Pu in Record
Form 4 MAY "
DEP has provided this form for use by local Bo tJs cord mu:be submitted to the local Board of Health or other approvngt N•r
A. Facility Information -
Important;
When filling out 1. System Location:
forms on the
computer, use
only the tab key Address�� - --- ----- -to move your
cursor•do not City/Town --'—" ------
use the return State Zip Code- -
key. 2. System Owner; l_
m
--12 kzzz,�
C
Address(If different from location) '•
C ity/TownState ---•------
/E—Y�2 427
Telephone Number - -
. Pumping Record
�r.
-. t Date of Pumping p -_ 2. Quantity Pumped; = ._._...
Gallons
3, Type of system: ❑ Cesspool(s) ,.❑" Septic Tank ❑ Tight Tank
❑ other(describe);
Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ Na
r
5. Condition of System:
61 Sy em Pumped By:
ame -----..............
AT I 1�0 Z Y�
Vehicle License Number
Company _
7. Location where contents were disposed:
Aw
Si ature of Hau Date -------- - --- --- -
http://www,mas§.,gov/dep/water/ provals/t5forms.htm#inspect
t5form4.doe,06/03 System Pumping Record-Page 1 of ,
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DER has provided this form for use by local Boards of Health. a System
be submitted to the local Board of Health or other approving au or1ty, Pum{ "-'R-ec d must
A. Facility Information � .� � '- 200
,. important,
-,� yvhen Ong out 1 . System Locatlon �. I � r°
�� t
u forms on Utah �9 Rw,�u.�� e ..W_�'�I�. T
computer,usa .
only the tab key Address
to move your
cursor do not
use the rotum City/Town Stat.
Zip code
<, key System m Owner, '
} r. Nama
Address(If different from location)
CltyrTown State
Zip Code
Telephone Number
Pumping Record
1.: Date;of Pumping Date 2, Quantity Pumped;
Gallons
Typo of system.'
ystem, ❑ cesspool(s) eptic Tank ❑ Tight Tank
l
❑'Other(describe);
4 Effluent Tee Filterrpresent?'. Yes I y as it
cleaned?i r s, ane
l ^
® f e w ❑ Ye o
5; condition of:Syst�m;'' .
1
6 Sy em Pumped BY'
I ..
� I t r b ;f'}, � 1 tt 14}' '":+'�� 'iii" r�N ,L � �•�!-• .'�Vahlclo,,,U///cyyya���n///g���e Number .
7 t4
CGnipany..�r
.Iairr. .�'yvh
Locaflon where contents Were disposed;
t
Slonatura of Hauler;,yr c•
Date
http.//www mass gov/dep/water/apfprovals/t5forms,htm#Inspect
t5forrn4,doc+f)8/03 System Pumping Record-Page 1 of i
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP 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 authority.
A. Facility information
Important:
When filling out 1. System Location:
forms on the
computer, use ?,q
only the tab key Address
to move your L
cursor-do not City/Town rZ&�/
use the return State Zip Code
key. 2. System Owner:
tab
e
Name
erwn "A
Address(if mattED
-City/Town State Code
MAY 1 1, 200G
Telephone Number
TOWN()F W)R,'TH ANJ,)OVER
R =fqy
HFALI'H[)EPAOWE.
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
,Zf�
Gallons
3. Type of system: El Cesspool(s) &19�ptic Tank ❑ Tight Tank
❑ Other(describe): ✓
4. Effluent Tee Filter present? bl-des ❑ No If yes, was it cleaned? ❑ Yes No
A
5. Condition of System: \ %
(4
6. System Pumped By:
Name Vehicle License Number'
x.1W W
Company
7. Location where contents were disposed:
Signature Date
http://www,mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: _ '..
SYSTEM OWNER chi ADDRESS SYSTEM LOCATION
(example: left front of house)
- .,
DATE OF PUMPING:3`_� QUANTITY PUMPED A5W 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 EV:
i
COMMENTS:
i
CONTENTS TRANSFERRED TO:
Conmiontive !th of Massachusetts
x,4'4
µ -' , Massachusetts
System Pumping Record
System Owner System Location
Af�
Date of Pumping: Quantity Pumped: C gallons
Cesspool: No Yes U Septic Tank: No Yes L�
I
System Pumped by: gctre4v<t 1&1Q ftaa License #
Contents transrerrred to : Greater Lawrence Sanitary District
Date: Inspector:
i
Torn �qf North Andover.
Watershed Septic Systems
Servicing Report APR
,9
Date: 3/24/99
Homeowner: WILLIAM RAYTA Pumper RAGGS SEPTIC SERVICE, INC
Street 89 BRIDGES LANE Address: P.O. BOX 1027, CONCORD
Phone Phone 978-369-1100
Nature of Service: Routine X
Emergency
Observations : Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other (Explain)
Description of Work:
ROUTINE SEPTIC PUMPING
Comments:
Town of North Andover, MA
Watershed Septic System
Servicing Report
Date: 4/9/98
Homeowner: WALTER RYTA Pumper :RAGGS SEPTIC SERVICE, INC
Street 89 BRIDGES LANE Address.-P•0. BOX 1027, CONCORD
Phone Phone •978-369-1100
Nature of Service: Routine X
Emergency _r
Observations: Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other (Explain)
Description of Work:
Comments:
