HomeMy WebLinkAboutSeptic Pumping Slip - 104 BRIDGES LANE 1/6/2016 I
Commonwealth of Massachusetts
w v City/Town of No Andover JUN 1
o
System Pumping Record RTHANDOVER
Form 4 PAR"rt�EGVT
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 t)" r
key to move your Address
cursor-do not No andover Ma
use the return City/Town State Zip Code
key.
rah 2. System Owner:
f:� . .
Name L
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) ff 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
c�
6. System Pumped By: ..,.42--
,.
Name Vehicle License, umber
Stewart's Septic Service
Company
7. Location where contents were disposed:
Ste\6rt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03106 System Pumping Record-Page 1 of 1
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Commonwealth! of Massachusetts
i ..own of NORTH AN-DOVER MASSAgHUSE TTQ
System Pumping Record..
Form 4
DEP has provided this form for use by local Boards of Health. The System Pum ` g Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important 1. System Location,
forma onl bout 0—/ lone
computer,use
only the tab key Address it 1�1 r ,
to move your ' ` L l
cursor•do not Cityrrown State Zip Code
use the return
key...., 2. System Owner, r
Name
Address(If different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record /` 0
/U/��A
Quantity 1. Date of Pumping Date 2. Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [3 Yes ❑ No If yes,was it cleaned? ❑ Yes [I No
5. Condition of System:
X/Y.
6. System Pumped By:
e I Vehicle License Number
Company
7. Location w efe contents were disposed:
0
Signature of Hauler Date
http:/twww,mass.gov/deptwater/approvaM5forms.htm#lnspect
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SYSTEM P MPINQ RFcoRL)
SYSTEM U ER ADDRESS SYSTEM LOCATION
� 0o-5if",
...................
DATE OF pUMPiNU; ..._T QUANTYTY PUMPED, /s
77
Ct��;spo()L: N\O. .._...... YES,. . . .. SOOC Tank: NU
YES
NA SURE CAN SERVICE: R0u'PINk
UbaE'RVATIONS:
UOOD CONDITION Fug rU CovER � DEC 0 �
00 �.
REAVY OREASE BAP,F BS IN PLACL
ROOTS -.._ t,Bi4CHP1ELp RUNBACK
sXCUSiVE SOLIDS FLOODED
SOLID CARRYOVER
OTHER EXPLAIN
1
5y.tem Pwnpcd by .
CUMMENTS.
CuN It m's fKANSF'ERR L) I'G
777,
' � � ,i�'YY7777�� v�t��l��•'� i1�� tip r�i Ali"�� G��� .0�, 1� ,s �;�z
'.1�eY ,�{ 1,Ft M��tir .`�_ I}1 tiN 1, ��➢Ipi �' � o.. '. � : /' �r� � � t� �p�kYG,17�4� ���
OW :'N0; .: H ANDOVER
S " Fpm, P�,T ':fN( C( W:
— e- �3 CD
SYSITH OWNC?.FC&
/V 0 , oAt)Ove .
C SSP00L NCB
_� dS � "TIC TAB N� 4
'n,'s
NATURE OF 3F-RVIC ,;,jZ � F� �•
t R(JENCY
OBSERVATIONS:-
0 /✓COND i 1 y"pf• ",r FULL ry C r4W re b
yy �� S LACB
vy CM
SYSIF117M PUMPED 13Y 7..
ID To
CONTENTSTRANSFERRE
( ry
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: c
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
C (example: left front of house)
DATE OF PUMPING: , ` UANTITY PUMPED I5T GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES .
NATURE OF SERVICE: ROUTINE VX EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
T D BY: �
SYSTEM PUMPED
COMMENTS: I ( "! f AMY
r/G
d
CONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
S 1'STEM OWNER & ADDRESS
SYSTEM LOCATION
(example; left front of house)
DATE OF PUMPING: QUANTITY PUMPED l
/�� GALLONS
CESSPOOL; NO
YES SEPTIC TANK: NO YES X_
NATUR.E OF SERVICE: ROUTINE
EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO
HEAVY GREASE COVER
ROOTS ------ BAFFLES IN PLACE
EXCESSIVE SOLIDS �— LEACHFIELD RUNBACK
SOLIDS CARRYOVER FLOODED
OTHER (EXPLAIN)
-SYSTEM PUMPED BY:
BOARD OF HEALJ k�
n
i
:O.MMENTS:
1)_NTENTS TRANSFERRED TO;
.'FbjR 14 « SYSTEM i Pb1EP NG PECdRD
107 Forest St,
Middleton,MA 01949
(508) 774-2772 \G v G
Commonwealth of Massachusms
X-) •�. , .Massachusetts
Wem
Sy sleet \v,ner
'
4
'bate of Pumping:��C.� � U�
Quanut) Pumped., .gallons
Cesspool: 1.o Yes
❑ Septic Tan};: ho ❑ Yes
S\'Stem Pumped bN; License #:
-Contents transferred to:
Date Inspector
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