HomeMy WebLinkAboutSeptic Pumping Slip - 140 BRIDGES LANE 1/6/2016 �L\ Commonwealth of MassaQhusetts
City/Town of 0 .
System Pumping Record
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 RF CEIVED
Important:When
filling out forms 1. Svste opat% 3 2 0 15
on the computer,
77�
use only the tab tX)VLL
key to move your Address
cursor-do riot bw
use the return a --
key. City/Town State Zip Code
VQ 2. System Owner: zle,
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 6 1- 2. Quantity Pumped:
Date Gilforis
3. Type of system: ❑ Cesspool(s) Septic Tank F-1 Tight Tank ❑ Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sys pm:
6. System d By:
ir
Name UMI— Vehicle License Number
Stewart's Septic Service
Company
7. Location whert�contents were disposed:
I I
Stewart' / re-treaftpt-P)brit, 20 So. Mill Bradford, Ma 01835
Si7tur 1-1211.�,,Xe, Date
Sig of Receiving Facility Date
t5form4.cloc-03/06 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System i Record
Form 4 "t� f�NORTH ANDOVER
HEALTH DEPARTMENT
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 CM 15.351.
A. Facility Information
Important:
When filling out 1. System Locatio : / ( /
(compute use 1 C
only the tab key Address
to move your North Andover ma 01886
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City(rown state Zip Code
Telephone Number
B. Pumping Record _
1. Date of Pumping Dat/ / 2. Quantity Pumped: Gall
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:
(.y n Ind
6. S n67-L m Pumpe
N Be I Vehicle License Number
Stewart Septic Service
Company
7. Loca on here contents were disposed:
Ste treatment Plant 20 So. Mill St, Bradford Ma 01835
Signs ure o auler Dat
Signature of Receiving Facility Date
t5forrn4.do(,-03/06 System Pumping Record•Page 1 of 1
TOWN OF
DATE: M ER
HWFA TM DE�AR'TMEON'T
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(a (example: left front of house)
f/'j
d Lv\
t
DATE OF P I NG: ` ' � _ QD Y P ED : t. GALLONS
CESSPOOL: NO YES SEPTIC T : NO YES
-7 NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCE SSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTHER(EXPLAIN)
SYSTEM PumPE,D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFEMED To: G.L. . Lowell Waste
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING:-� QUANTITY PUMPED K*V'--" 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 LEACHF1ELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
FORM A e SYSTEM P �
t. Ot Ottt. t
Commonwealth of Massachusetts
Massachusetts
ys, teen Pumine Record
--stem wner V tent ocatton
Lqf
4J,
Date of Pumping: Quantit} Pumped: gallons
Cesspool: No „Yes ❑ Septic Tank: No ❑ Yes
System Pumped by- _ � _ License #:
Contents transferred to: �
Date Inspector