HomeMy WebLinkAboutSeptic Pumping Slip - 101 BRIDGES LANE 1/6/2016 ,r RECEIVED
Commonwealth of Massachusetts
City/Town of ro
_ System Pumping Record NORTH ANDOVE TOWN OF
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 riling out 1. System Location:
forms on the -A/��-" ;computer,use only the tab key Addre
to move your
cursor-do not Cityfrown — --- State-- -- - Zip Code
use the return
key. 2. Syste wner:
Name
Address(if different from location) --.. --- — -----
City/Town — — State Zip Cod
�%
Telephone � � � ( -----
B. Pumping Record
1. Date of Pumping Date–� — 2. Quantity Pumped: Gauon—5 ----
3, Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ------_._____ ___-- ---- -
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? ` Yes ❑ No
5. Condition of Syst .
6. System Pumped By:
Name Vehicle License Number
Company A
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
city/Town of
System pumping Record T ANDOVER
Farm 4
rds of Health,DEP has provided this form for
the local s that provide d here. Refore >asing thi form,check with your
information must be substantially fitted to The
local Board of Health to determine the form theY us . within st days fr1 m t
the local Board of Health or other approving
accordance with 310 CMR 15.351.
A. Facility► I formaflo 1 TOWN of NORTH ANDOVER
HEALTH t PARTMENT
Important: 4 stem Location:
When filling out y —
forms on the ( 1 .
compulor.use _ . _.. ....._ . ,y'J C
only the tab key Address IV
to rpPve your _ . :.. ....
�` .. Q state Zip Cade
tursor-do riot -- ._w..
ci{ylTown
use the return
key. 2, System Owner;
Narim
s
�,. Address to diF[er+rnt from lacationt
—..,.,.. ..._._.w_
.__.,. ._..,. .... . Zip Code
T phon umber
B. pumping Record
Date 2. Quantity Pumped;
1. Gate of Pumping Geuans
El 3. Type of system:
cesspool(s) Septic Tank C] Tight Tank ❑ Grease Trap
❑ other(describe): _. . .._ �......
nt Tee Filter present? Yes ❑ No If yes, was it cleaned?' ( Yes ❑ No
4. trfflue 4..�
5. Condition of System. .fir
6. System Pumped y:
Nam
_..� .. 1'�:��.. '•'`•`__,....._...---. -°- �;ehisle LiG�nse Number
Company
7. Location where contents were disposed:
IDS
signature of Hau
ier
Signature of Receiving FaGltlty
System Pumping Record•page t of 1
t5form4.dac 031�ti
Commonwealth of Massachusetts
City/Town of
- - System Pumping Record NORTH AND V ER
y Form 4 TOW OF-M rfri 1ANr)0\TFt
DEP has provided this form for use by local Boards of Health. Other fo i I ' m
information must be substantially the same as that provided here. Before using this form, check wl h 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 on the r
computer,use
only the tab key Address
to move your �/, p i /° ---- — -- -1. Y-✓ ------ t a —
cursor-do not Cityrrown State Zip Code
use the return
key. 2. System Owner:
Name U_--
_ _ -----
�+�° Address(if different from location)
CitylTown State _ Zip C o e —--
Telephone Number
B. Pumping Record
1. Date of Pumping —Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) >9 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - ---- -- -- ----
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? NV Yes ❑ No
5. Condition of System:
6, System Pumped By:
� r
Name ,-.
vehicle License Number
2,6 _—�%�✓t'ion M
Company
7. Location where contents were disposed:
r
Signature of Hauler Date
Signature of Receiving Facility - -- Date -_ — ----- -—
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
|
Commonwealth of Massachusetts
�
City/Town �T NORTH '��[]0��� MASSACHUSETTS
. , ~~ . ~_. .
���ste�� Pumping Record
|
° " ~~ `��
Form
DEP has r",^d~d this form =for use by local ""="° "' Health." The /
be submitted to the local Board of Health or other approving autho ity.
�
�
A.. ^ .-~....y Information
�
'TOWN OF NORTH ANDOVER
Important: HEALTH DEPARTMENT
When filling out 1. System Location: �
forms onthe
computer,use
only the tab key Add �
m move your
cursor'unnot 6 W VAR H
use the return CityrTow?F ^."," Zip Code
key, ` ~
2, System Owner:
C C, fjA Jlt q C, C, le Ac
Name `
Address(if different from location)
�
|
City/Town State Zip Code
Telephone Number
B. PQOMp^Dg Record
1. Date of Pumping Date 2. Quantity Pumped� Gallons
' 3. Type ofsystem: Fl Cesspool(s) [�]�epUcTank El Tight Tank
F] Other (describe):
4. Effluent Tee Filter present? Fl Yea [�rNo |f yes, was i( cleaned? 2~Yos Fl No �
5, Condition ofSystem:
__-_______
S. System Pumped B
642
Vehicle License Number
»� �
��"o�U ~��.D
.
~~. .,...'
7 Location --- --
� �
'---------
Sig
http:0vmww.manx.gov�ep/v�8eRz�tpprova|sA 5 fonno.U{nn#mspaol
tuwnnx.doc onmn System Pumping Record'Page 1m1
Commonwealth of Massach
n _
City/Town of NORTH ANDOVER SSACH'lJmi
System Pumping Record
' Form 4 JU 00
'a¢,W' \i O roe F,T M I A�,c�����ER
DEP has provided this form for use by local Boards of Health. The Syri °I � tlr�U6mu t
be submitted to the local Board of Health or other approving authority. w .. .. .
A. Facility Information
Important:
When filling out 1. System Location:
forms on the (� f
computer,use
only the tab key Address
to move your UG')V if fi r, _ � Vt,\_.
cursor-do not ` !
use the return City/Town State Zip Code
key.
2. System Owner:
Name - — —
Address(if different from location)
City/Town State Zip Code
zY 7V 7 � f c °
Telephone Number
B. Pumping Record
1. Date of Pumping 7b& 2. Quantity Pumped:
Da e y p Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [ Yes*o o If yes, was it cleaned? Yes ❑ No
5. Condition of System:
-- ( �-o o d---
6. System Pumped 7,
Name --
W r E Vehicle License Number
Company
7 -boation where contents were disposed:
Signature of Hauler ate
http://www.mass'.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
FORM 4-SYSTEM PUMPING RECORD
l✓
1 01949
'� 6��i 0%/ / /oi /,� / �/�7/✓ /
�� �` �y/�� ���/'/ rra��j ✓ irn9�ll�l
�1
I-
C + 1I t1�l AL'I'H OF MASSACHUSETTS
12 ' VC's ,MASSACHUSETTS
�N
SYSTEM LOCATION:
y
z )1dj 'o
Y i / 11 u f.i ,,,
rlir�� /f ,
N` 'JNQ %V77 QUANTITY PUMPED: lod ALL J►
SEPTIC TANK: NO YES
vV
ov
r�4! �� r� ��� d(/✓ �l /i /
� 5
r /1�A� �f'1�llrlinl,'�i��,rN Ni r,
w/ INSPECTOR: Ge'°Q f'
r v
f
r r i/i
FORM 4-SYSTEM PUMPING RECORD
U`Y T d
URRIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET;MIDDLETON,MA 01949
(978) 774-2772
i
ii
COMMONWEALTH OF MASSACHUSETTS
w�IN17C1vcZ ,MASSACHUSETTS
,SYS'TE'MPUMPIN(r RECORD
SYSTEM OWNER: SYSTEM LOCAT ON:
�G
/01 N44 b/ /V-gm7jv¢K Cc,.o4�t
DATE OF PUMPING:
QUANTITY PUMP D: f GALLONS
CESSPOOL: NO YES F7 SEPTIC TANK.: NO YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SER CE
CONTENTS TRANSFERRED TO:
DATE: f `"�2S INSPECTOR:
Forest
St.
Middleton, MA FORM 4 - SYSTEM PU;\ZPL'NG R.EC01W
iddlelon, MA MA 01949 ,�Q4P''
(508) 774-2772 �.Qlvcs C�
AV
ca ��� k
�,
r �1 r
Commonwealth of Massachusetts
Massachusetts
ystent vtn g Qc®r
VT ystem Location
�
Date of Pumping: /7) ,- )- � r..
`� ----------_ Quantity Pumped: L-? yallons
d
Cesspool: No ❑
Yes ❑ Septic Tank: No ❑ Yes
SYstem Pumped b%-: `i `> ��:.' `�� { � c' �� � - �
Contents transferred to: � License #: .. _
I
Date
Inspector
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