HomeMy WebLinkAboutSeptic Pumping Slip - 274 FOSTER STREET 2/9/2016 - . - ^
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Commonwealth of Ma � sachu |
RIM C0'iV/ { V/ of North Andover
K� ��u00��'�� ������� '
° ` Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be uoed, but the
information must be substantially the same as that provided here. Before using 'this form, check with �
local Board of Health to determine the form they use. The System Pumping Record must beouhmiatte
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCMR15.351.
A. Facility Information
Important:When
mUngmut forms 1. System Location: - - -- -
^n the computer,
use only the tab 27q
key to move your � ---~~'-------- ---'—H�-g+��`~�°�--^���---------
cursor-donm
North- --_� �
key. City/Town atate Zip Code �
2. System Owner �
Name
�------ Addreao(,f �
� �va
� �from on----' - -- -' '—'- ---'-------------------------
Cityrrnwn �-�--'----------'- -- - State------------ —Code-------Zip
B. Pumping Record
1. Date of Pumping 2, Quantity Pumped:
Date"' d118�s
3. Type ofsystem: El l(s) Septic Tank Fl Tight- Tank Grease Trap
Fl Other(describe): ---
4. Effluent Tee Filter present? E] Yes cf No If yes, was it cleaned? F_� Yes F� No
5. Condition ofSystem:
- -
wavm ��-�-------'-'---- T��Ge License Number------
Stewart's Septic Service
Company �--------' --- --
7� Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Brad4 rd, Ma 01835
agnamreof*avhv �--------' -------'-'- -----
' oa�
8g��v�ufeaoeivinsp�c�y --- - ' -' --' �Da te�---- '---'' -------------
k5fw��oc-03/06 System Pumping Record-Page I o
Commonwealth of Massachusetts RECEIVED
City /Town of North Andover FEB 14 2017
yYO
System tem Pumping Record � IH
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..
1. System Location:
North Andover
City/Town
2. System Owner:
Address (if different from [motion)
City/Town
umping Record
1. Date of Pumping
3. Component:
State
Telephone
—0
Date . Quantity Pumped:
Code
Zip Code
1(3�
Gallons
❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Z4 No
5. Observed condition of component pumped:
`fc
If yes, was it cleaned? ❑ Yes ❑ No
6. System Pumpe�. 47
Name Vehicle License umber
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
s
of Hauler
o'e-3
Signature of Receiving Facility (or attach facility receipt)
7-1
Date
Date
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