HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 2/9/2016 commonwealth of WJassachusetts
: 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 wi
local Board of Health to determine the form they use.The System pumping Record must be subm
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. FacHity Information
Impor`ant:When
51ingoutforrns 1. Sy tern Location:
he computer
us_ my the tab --°-"---
key to move your Address
cursor do not NorthAridover --- --- "'_--"
use the return
Zip Code
key. Giyffown w c
2. System Owner
h4i' C' ----
Name
lAdes f dd m ocl on
...-....._..... ...- -'tat-'--'-.__.
Se
Telephone Number _
8. Pumping Record
�—:r���✓ _" _���-�-'i
1 Date. Date of Pumping °--- „„a,2. Quantity Pumped. Ganons
3. Type of system. ❑ Cesspool(s) ,Septic Tank ❑ Tight Tank ❑ Grease 7
Other(describe):
4, Effluent Tee Filter present? ❑ Yes❑ No If yes,wash cleaned? ❑ Yes ❑ No
5. Condition of System.
6. System Purpped.,By:
N�m„,�,w- Vehicle License Number
7. Location where contents were di posed.
Stewart's Pre-treatment Plant,20 So.Mill Bradford,Ma 01835 --
Commonwealth of Massachusetts
City/Town of North Andover
.System Pumping Record
Form 4
DER has provided this form for use by local Boards or Hearth.Other forms may be used,buf the
information must be substantially the same as that provided here.Before using this form,check wi
local Board of Health to determine the form they use.The System Pumping Record must be subm
the local Board of Health or other approving authority within 14 days from the pumping dare in
accordance with 310 CiMR 15.351.
A. FadHty 9nformaton
Important When
Suing out aims 1. System Location_
on the computer, .1 y
use only the
key bmove your Address
cursor-do not No Andover
use the return --_—__..._._.. _... .... _......... ___—__.
,k ____......___......_.. .._..__--.—_
ey CRy/TOwn Staye Zip Code
2. System Owner,
Name
Address(if different from location)
_._,-.
Cityrown S,zte Zp Code
- Telephone Number
B. Purrlp�ng Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system. ❑ Cesspool(s) Septic Tank ❑ Tight lank ❑ Grease Tr
❑
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
Stewart's Septic Service
Company
7. Location where contents were disposed
Stewart's Pre-treatment Plant,20 So.Mill Bradford,Me 01835