HomeMy WebLinkAboutSeptic Pumping Slip - 600 SHARPNERS POND ROAD 2/1/2016 V
i
al
Commonwealth of Massachusetts
City/Town of
r �'r
System Pumping Record NORTH- t �4 Al orm--
. t
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 j
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 ion: m. -
forms on the _
computer.use 1. System OCa nd _
only the tab key Address
to move your
cursor-do not
CitylTown Stale Zip Code
use the return
key. 2. System Owner:
Name
1
Address(if different from location)
City(Tovvn State(( Zip Code
Telep ne Number
B. Pumping Record
1. Date of Pumping -Date �� 2. Quantity Pumped: Gallons
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 cteaned? ❑ Yes ❑ No
5. Condition of System.-
6. System Pumped By.
Name Vehicle Licens Number
Company
7. Location where contents were disposed:
Signa u e of Hauler Date
...___,.__.. ..........___---____._
Signature of Receiving Facility Date
l5form4.doe 03/06 System Pumping Record-Page 1 of 1
&' Commonwealth of Massachusetts
C' [7 of \
System Pumping Re
Form cord NORTH ANDOVER
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 ow that provided hone. 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 14days from the pumping date in
accordance with 310 CIVIR 15,351. R_" '11 ED
A. Facility Information
Important: .
When filling out 1 SyobemLomati�n� 7+1 ANDOVER
���the TOWN OF NOR7+1 ANDOVER
computer,use -___�~� ��_~� ,
only the tab key *uoexx
m move your
ovmn,-uonm --------------------'- State Zip Code
use the,omm City/Town
key. 2. System wner:
Address(if different from location)
mamo
._��____-______-_- °
Q��Town owm Zip Code
Telephone Number
B. Pumping Record
�
1. Date ofPumpng 2� Quantity
Date 1 Type ofsystem: [l Cesspool(s) cTmnk 0 Tight Tank El Grease Trap
[]
Other(describe): -----�-------- '------- --'-------- �------�----------
4. Effluent Tee Filter present? 0 Yes El No |f yes, was itcleaned? El Yea El No
5. Condition ofS :
L/ '
S. System Pumped By:
~=�IQ
^ =�_~=�-___-__-_____-
' /&ame �7 \ k' ,"'""'e License
~"'"""'
/~ ~ _~
cumparwy
�
7. Location where contents were disposed:
------ --'--'--------'-------- ------------- -- |
. � �� �
�K�����A��o� ����u��K
.
-signature o|H uler � , v Date
-
signatur
-W -117,7 Date
of Receivirl
t5form4.doc-03/06 System Pumping Record-Page 1 of 1
a,,
Commonwealth of assacbusetts
City/Town of
System Pumpi PgReco: r
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 Purr,!Pii,,,pg,,.Record-,,m,u-st-,be-su itt d to
the local Board of Health or other approving authority within 14 day m tqq,]�4fti W6",'A)e in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out I. System Location:
forms on the 6
computer,use
Y the tab key Mires
cursor-do not
to move you r I k U— M,
use the return CityTTown State Zip Code
key.
2. System Owner:
o a
Name
Address(if different from locatio--nT'
CityfTown State Zip Code
7Telephone Number
B. Pumping Record
1. Date of Pumping U161 Quantity Pumped: )C)
Date Gallo A
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. Conditi of Syste(:
6. SystAm Pumped By:
1+
Name Vehicle License Number
Company
7. Location where contents were dispose
c"
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06" System Pumping Record-Page 1 of 1
I
Commonwealth of Massachusetts I
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record I
Form 4
l
DEP has provided this form for use by local Boards of Health. he uTpjpg Re ord must
be submitted to the local Board of Health or other approving a thortty.
A. Facility Information w 7 7006
Important: °p-OM,1 O NO
ewd I ��L..i C I h 1!I ��[ 1 I/tk i d.I." ....
When fining out 1. System Location: � � " " "
forms on the
computer,use 4 U C'S
only the tab key Address `�
to move your nJ y 7� `—t e (E)
S
cursor-do not I!
use the return City/Town State Zip Code
key. 2. System Owner:
fib
Name
Address(if different from location)
CitylTown State Zip Code
`'T ? Ss''6 5 S
Telephone Number
B. Pumping Record -7 /0 1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. 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:
6. System Pumped By:
Name Vehicle License Number
i
Company -- - ----
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
Foam 4 -- System Pumping Record
Commonwealth of Mossachusotss
: Massachusetts
Svstem Pumpina Record
System Owner system Location
:,t v ,21n94?� ���} �;l,ku,P i%✓�hr'% t%k�% ,r!r,Y,.,1���,,.,a ,,-%l'�7i� r s,, �
Type Emergency Routine
Cesspool: W Yes septic tank; Kb Yes
bate of Pumpings b quantity Pumped: (' Gallons
System Pumped 6y: Wind River�hvie�o�rft�ilt al, UC Permit :
l
Contents transferred to:
I
Contents Disposed at
I
Date::, � Pumper signature:
Condition of system/. r Comments
Dg , P, ved From - 12107195
Form 4-- System Pumping Recard
Commmealth of Mos"rhusetss
RECEIVED
D
[,RECEIVE
U
JUL, - 9 2004
0
VER
TOWN OF NORTH ANDOVER
H i�
Ll M
P T T
EALTH DEPARTMENT
Syst tion f
System Owner
J 8)
Type: Emoray Routine
Cesspook w Yes septic tank: No Yes
bate of Pumping: Quantity Pumped: XpGoltans
System Pumped By: Wind Rimp Envftnxenfal UC Permit
Contents transferred to:
Contents Disposed at
Date: Pumper Signature:
Condition of Systam/Other Comments
1100,
by Approved Form - 12/07/95