HomeMy WebLinkAboutSeptic Pumping Slip - 656 FOSTER STREET 2/9/2016 Commonwealth of Massachusetts
CityfTown of North Andover
SYstem Pumping Record
Form 4
DEP has provided this form for use by local Boards of Heal'�h. 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 Sys-Lem 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. Facifity Wormati®n
Important:When
filling out forms 1. System Location:
on the computer,
use only the'Lab
key to move your .......
cursor-do not Address f
use the return North Andover
key. Z_iy/_To-n State i
Zip Code
2. System Owner:
Name
mon
Address(if different fror�_i_o_c location).__
Address
City/Town
_ State
Zip Code
Telephone Number
B. Pumping Record
ng
1. Date of Pumpi bate Y- Quantity Pumped:
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Try
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes ❑ No If yes, was'itcleaned? ❑ Yes ❑ No
5. Condition of System:
............
6. System Pumped
Stewa 's Septic ServK15_—"_____ Vehicle License Number
rt
Company
7. Location where contents were disposed-,
Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
Signature of�Hauler ----.---'--""-_-
Date
ignature�cf Recjiv`[ng_Fa_ci"I�-'Y Date
k54orr-.14.doc-03/06
System Pumping Record-Page
�
Commonwealth nfMa,� achusetts
City/Town mf ��� rf� � ��
» "+ North Andover
System ������
~�- Record
'
` . ' _
Form 4
DBP has provided this form for use by local Boards ofHeabh Other forms may beumed b. the
infonnat�nmust beaubstsn�aUy the same eatha� pnov�ed 'are 8efonausingthia �-- ��u^,
|«oa| BoardofHea|thtodetenninethofonntheyuse. ThaS ~~- PumpinQRecord ='� �x��» «wm�
the �oa| BoardofHea�horot erapp/ovngau�o�«�hhin'-~'^ ' fn�� thepumpi"=""'�iuuv"ou�
accordance w�h31OCy�R15.351. ' ' pumping date ''
A. Facility information
Important:When
nllinQout forms 1. System Location:
un the computer,
use only the tab ' / [
key m move your
cursor'donot
use the return Andover
key. Wrown ---- ---'-- ' —'------------ -___
State- Zip Code
Z System Owner: �
�ame ��'- ---- ---'----'--------------
xudean(if umerenfmm tion ...... - - -- '-- --'-'------------------------
ox�rown -------------- -- -----------'--- _ �
-- ��^""=
'==p""e Number �
B. Pumping Record
1 Date ofPumping ---�`-- -v' /&�`�� Ouont�yPumped� Gallons 3. Type nfsystem: D l(s) Septic Tank E7 Tight Tank El Grease Trap
0 Other(describe): ------------
'--_` .�---__----------'-'---'--
4. Effluent Tee Filter present? Yes Fl No If yes, was it*cl�aaned? El Yes No
5� Condition ofSystem:
- ---' ----- ---------------
6, System Pumped By:
..a�e �--------- --'-------''-_-'__-_'__--------
Vehicle --
StevvaryaSe ti Service mm �
Company �----------- --- '-
/. Location where contents were disposed:
~ 20 So. Mill Bradford, Ma 01835________
§7,9nauvmnr*av|er �--'-.---'-'---'- -------- ''-' ' -----
Date
x�no�naofeeoei�ng��cnhv '
uate --
5 mnn4.ouo'uomn
System Pumping Record'Page 1 o