HomeMy WebLinkAboutSeptic Pumping Slip - 128 BRIDGES LANE 1/6/2016 Commonwealth of Massachuset
City/Town of NO ANDOVER
System Pumping Record
MM
w:
Foram 4
47A
J°0VlfN 01, NO R1 I A, 1,(!pw k'�Fi &�w
DEP has provided this form for use by local Boards dirif ". 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 forms 1. System Location:
on the computer, 128 BRIDGES LANE
use only the tab _
key to move your Address
cursor-do not NORTH ANDOVER MA
use the return City/Town State Zip Code
key.
2. System Owner:
r� FARIS
Name
reArn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record k5a)
1. Date of Pumping D-51 eR 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ONo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
U
6. stem Pumped 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
„,_Signa rofl4auler Date
ignature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
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 CIVIR 15,351,
A. Facility Information
an filling out 1. System Location:
as on the
aputer,use
I the tab key 'Address
nove your North Andover ma 01886
sor-do not City/Town State Zip Code
the return
2. System Owner. rl�'
RECEIVED
Name
Address(if different from location)
TOWN OF NOR14ANDOVER
7-1 M0011 DEPARTMENT
City/Town State
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: ky�n
Date Gallons
3. Type of system: F-1 Cesspool(s) 92-Si-ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? r-1 Yes ❑ No
5. Condition of System:
6. e em Pumped By:
Name Vehicle License Number
Stewart Septic Service
Company
7. Location where contents were disposed:
Qtew,arls P treatment PIaqt2(XSo. Mill St, Bradford Ma 01835
Signature ladier Date
Signatury f Receiving Facility Date
wm4.doc-01W System Pumping Record•Page 1 of 1
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Commonwalth,�f Massachusetts
. ity�own 6f•N RTH ANDOVER A AC U ED
7 -:System uping Rear
Form 4 TIQV . n2006 ,
DER has provided this form for use by local Boards of Health. The � ?� 'must
be submitted to the local Board of Health or other approving autho
A. Facility Information
Important:
When filling out 1. System Location:
forms on the , ( ! ltlz
computer,use
only the tab key ddress p
to m y
move your
cursor-do not City/Town ! State Zip Code
use the return
key. .., .-:.• ;
2. System Owner:
OL
Name
�m Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
Date- 2.Pum in 2. Quantity Pumped:
.� p g Date Ga ons
Type of system: ❑ 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: r �'
l
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents.were disposed:
�a 1440 of , n1a
Signature of Hauler Date
http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
RECEIVED
TOWN NUR1'M ANDUVE
u^rF ° P�7` cjC `�YSTE PUMPIN RECORL) cr y
SYSTEM" OWNF>R & ADDRESS SYSTEM LOCATION
DATE OF PL[MPINO: —
_....,.. ..,. ? -_,.__..._QUANTITY PUMPED:...
Ck,SSfWL: NO _,...... YES,. Saptic 1'ank: NO YE.S '
N^ FURE OF SERVICE: ROUTIN1
................
r)8SF,RVA'rl0N8;
Q0OD CONDI'T'ION PULL T'U COVER
HEAVY GREASE 8A.FFLES IN PLACE ROOTS t-BAON'FIF.LD RUNBACK .._,._
FXC:ESSIVF,SOLIDS ......_. FLOODED _.
SOLID CARRYOVER, ��_OTH-Ep, EXPLAIN ,
5yrtom
pump-.d by
�'t>MMEN1';i.
_................_......_........._...... . ,..
..._..................
.._.._.._,._....., ....
CuN FEN I'S ['KANS1"'ERREl7 I'o
r
TO" OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 912�
�1'STEM OWNER & ADDRESS SYSTEM LOCATION
(exam ple. left front of house)
e
U:\TEOFPUMpINC: 9-Z I QUANTITY PUMPCD/5 , CALLO.",
NO YES SEPTIC TANK; NO YES
NATURE OF SERVICE; ROUTINE EMERGENCY
c)IISFRV,:\Tl0NS;
COOD CONDITION_ —��� FULL TO COVEI�
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER PQRHER (EXPLAIN)
i
s-1 L M PUMPED f3Y; �y.., G
C, U..M M ENTS;
UNTI,N"I'S tRANSFERRED 'T'O: