HomeMy WebLinkAboutSeptic Pumping Slip - 169 GRAY STREET 2/2/2016 i
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form A
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the
information must be substantially the some as that provided here.Before using this form,check with your
local Board of Health to determine the ingtauthority within 14 days from the pumping dale I�ubml►ted to
the local Board of Health or other app max,
accordance with 310 CMR 19.351.
A.Facility information tl
Important:
man filling out 1. System em
corms on the �4/f7 — 622! .�'` u CAV I
computer,use —— ( lr i Qi tau P I i(I V4 all i u 9
only the tab key Address
to move your �� yG��� r
cursor-donor State ip4e
use the return
CByfrown
k�ey� Z, System Owner
Name
lr" Address Iff different from location) _
21p Code
YQ
Telephone Number B. Pumping Record
1. Date of Pumping a Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) eptlo Tank ❑ Tight Tank ❑ Grease Trap
[] Other(describe): - - —
4. Effluent Tee Fitter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System.
6 System Pumped By:
' ehicie'License Number
Name
Company
7. Location where contents were disposed: Cl.LS.n.
.-N'ofth Ant;MBA- _
_
bile'
SignaWre of Mauler to
5lgnaiure of Receiving faculty — bate
system Pumping Record-Page I of t
t5form4.doe-03105
tw
Commonwealth of Massachusetts i
City/Town of NORTH DE :00:
System Pumping Kecora
Form 4 T,OWIW of-'h&W�8'��"i I-I ANDOVER
OVER
HEAdw:Tf 1 DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the j
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 1. System Location:
forms on the ` C"rv' l4 tj
computer,use --- — —
only the tab key Address p�
to move your Nc)�A\q /AY) 01\/ a — I t Zi �d
cursor-do not — ----- --...—-- — — —.__
use the return
City/Town State p
key. 2. System Owner:
� i ►c i s ur n) —
Name w
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
9 I '7 -0
1. Date of Pumping Date_ 2. Quantity Pumped: Gallons -
3. Type of system: ❑ Cesspool(s) L/ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): o
4. Effluent Tee Filter present? ❑ Yes [0 No If yes, was it cleaned? ❑ Yes Ltd No
5. Condition of ystem:
6. System \Pumped By:
--
�..,1 I YY1 `J �! lrl W ----
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler — —,,,. ,)+)(r��sf� rm' t� Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record-Page 1 of 1
i
I
• Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MA � w
System Pumping Record
Form 4 p g D ,,; 0, 8 Z008
DEP has provided this form for use by local Boards of Health. T e� ii �aIii �' � must
be submitted to the local Board of Health or other approving aut ortiy� I D'
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,user' °�(
only the tab key Address
c�sor edo not � " , ❑ h
use the return City/Town State Zip Code d
key.
2. System Owner: CPAC
• Name — —
t.
Address(if different from location)
) ew 'S...
City/Town State Zip Code
(r ,
Telephone Number
B. Pumping Record
1. Date of Pumping pate t 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
Company -- --
9 .� n a
7. Location where contents were disposed: t, f,,l � Mk
Signature of Hauler Date
http://www.mass.gov/dep/water/appro alsft5forms,htmffinspect
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Healt The System Pumping ecord must
be submitted to the local Board of Health or other approving auth o I
Important:
When filling out 1. 8Yobsrn Location:
forms on the
computer, use
only the tab key Address —~ �
to move your �
cursor'unnot
use the return City/Town state Zip Code
xny. '
2. System Owner:
Name V
Address(if different from loca ion)
City/Town State Zip Code
Telephone Number
/
|
B. Pumping Record �
1. Date ofPV0 'ng
Date 2. QUgnU� Pumped: Gallons
3. Type nfsystem: [1 (s) [9 Septic Tank E] Tight Tank
El Other(describe):
4. Effluent Tee Filter El Yes E9 No |f yes, was it cleaned? F1 Yes Ej No
5. Condition of System:
8. System Pumped By:
Name ' -- Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
hMp://www.masn.Qov/deo/watar/approva/s/t5formo.htm#inupeot
\5fonn4dno'06/03 System Pumping Record'Page 1of1
{
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER,. MASSA 410 ....
,TT � I
System Pumping Record
Form 4 f
J,
DEP has provided this form for use by local Boards of Health. The SystetwPurnping Records ust
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use (°- '- .
only the tab key Address /�
to move your 1) ) A n c)l.��"`�.� ,._�.- �r� � 9 ,,_
cursor-do not �' ``""�-- �
use the return City/Town State Zip Code
key. 2. System Owner:
I�
tab
Name
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) (/Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes FT No If yes, was it cleaned? ❑ Yes ❑ No
5, Condition of System:
6. System Pumped By:
Name t Vehicle License Number
❑, . _
Company
7. Location where cpntents were dispose
,,�""�❑ ..�°"Tr �",❑�❑..�� Mme,,,.°'" ,.....,.-.'"".,. �'� �+ /�h�..,„
Signature o Hauler Date 1
http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
1
F RM 4-SYSTEM PUMPING RECOO
C4 J I ....,
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON,MA 01949
(978)774-2772
COMMONWEALTH OF MASSACHUSETT
MASSACHU ETTS
SYSTEM PUMPING RECORD
d
i
SYSTEM OWNER: SYSTEM LOCATION:
DATE OF PUMPING: 3 c /S U U
QUANTITY PUMPED: GALLONS
CESSPOOL: NO F7 YES E:] SEPTIC TANK NO F--] YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE: / / INSPECT OR:
Pam 4 -m ;System Pumping Record
Commonwealth of Massachusetss
Massachusetts r'
�stom Pu�,rpdnq�ecna
I
I a
.Mmr-
System Owner System We ation
Wit `f
ry
Type: Emergency Pouting
Cesspool: Kb yes Seprtic tank: w yes "
r
Canto of Pumping: a 1 Quantity Pumped:
I
i
System Pumped By: WW River b7pimnMental, UC Permit
Contents transferred test
j
i
Contents bisposed at:
ot-66
.._..
i
Date: Pumper Signature.
Condition of System/Other Comments
i
I
Form 4-- System Pumping Record
Commonwealth of Mdassachusetss
i
Massachusetts
System PurnWM R Ilk) ��.~" t S „� � AG
J
system k °u ystepa do
r
Type: Emergency Routine LKI
Cesspool: hio Yes Septic tank: Pio Yes
Date of Pumping: 112zo i� (quantity Pumped: I Gallons
System Pumped Sy: Wind 11 w&VIMMIental, UC Permit ;
Contents transferred to:
Contents Gispo at:
kv
,V bate: Pumper Si to �
Condition of System/Other Comments
RECEIVED
0
TOWN OF NOR d H ANDOVER
HEALTH DEPARTr;"lENT
I
6ep Approved Form m 12/07/95
Para 4 -° System Pumping Record
Commonwealth of Mossachusetss
; Massachusetts
§ystem Pumping Record
1
System Owner System Location
W)J.°"rfi, "MI .F,ay„{C,, ,r",Asia" tQ6,,4,5 MA D18415
Type: Emergency Routine
Cesspool' W Yes septic tank; W Yes
bate of Pumping: /s Quantity Pumped: 45-0 J Gallons
System Pumped 6y Wind R'iw Environinental LXC Permit
Contents transferred to.
Contents Disposed at
Doti: Pumper signnivre: D�J�
Condition of System/Other Comments
i
i
Dep Approved From - 12107195 moo ��,