HomeMy WebLinkAboutMiscellaneous - 265 Johnson Street/I
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
4
SYSTEM LOCATION
(example: left front of house)
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DATE OF PUMPING: QUANTITY PUMPED._Z_Ai1L::ZALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
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NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PtMPED BY:
COMMENTS:
-.'/FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO:
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
SYSTEM OWNER & ADDRESS Sy
STEM LOCATION.
(example: left front of house)
Mr
14"
DAT L47
E OF PUMPING: & -
7
QUANTITY PUMPED Z�ZV GALLONS
Y
CESSPOOL: NO
ES sEpTj
K: NO YES
NATURE OF SERVICE: ROUTINE. "EMERGENCY
B RVATIONS:'
SE
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GOOD CONDITION'
FULL TO COVER
HEAVY GREASE
BAFFLES IN PLACE
ROOTS
LEACHFIELD RUNBACK
EXCESSIVE SOLIDS
FLOODED
SOLIDS CARRYOVER
OTHER (EXPLAIN)
�YSTEM
PUMPED BY:,
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14
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Commonwealth of Massachusetts
City/Town of North Andover [Mv 21 ZU12
System Pumping Record 'fNUKTHANDOkER
TH C5zPA9,T1'%:,;.NT
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.
stem Pumped By:
br,mink(
License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
St-qrt'% Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature
t5form4.doc- 03/06
Facility
Date
Date
System Pumping Record - Page 1 of 1
A. Facility Information
Important: When
filling out forms
on the computer,
I . System Location:
the tab
use only
key t6 move your
Address
cursor - do not
use the return
North Andover
Ma
01845
key.
City/Town
State
Zip Code
4:1
2. System Ow 7—
ner:
Name
_Kddress
(if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1 . Date of Pumping 2.
Date
Quantity Pumped:
15C C
Gallons
3. Type of system: Cesspool(s) I/ Septic
Tank F-1 Tight Tank
El Grease Trap
El Other (describe):
4. Effluent Tee Filter present? El Yes 0 No
If yes, was it cleaned?
El Yes r-1 No
5. Condition of System:
C rj
stem Pumped By:
br,mink(
License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
St-qrt'% Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature
t5form4.doc- 03/06
Facility
Date
Date
System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts
City/Town of North Andover
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
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
VQ 2
t5form4.doc- 03/06
System Location:
Address
North Andover
City/Town
System Owner:
N-ame
Address (if different from location)
City/Town
ohncsoy)
Ma
State
State
Telephone Number
B. Pumping Record
1. Date of Pumping /C)
Date 2. Quantity Pumped:
3. Type of system: El Cesspool(s) 11 Septic Tank F-1 Tight Tank
El Other (describe):
4. Effluent Tee Filter present? [] Yes E] No
5. Condition of System: x
6�._Pystem Pumpild By
01845
Zip Code
Zip Code
Gallons
El Grease Trap
If yes, was it cleaned? 0 Yes [:1 No
Vehicle License Number
Stewart's Septic Service
Company
7. Location where' contents were disposed:
.4tewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
�,) - -___j
Signatur uler
SignatUre of ReceRing Facility
Date
Id
Date
System Pumping Record - Page 1 of 1