HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 1/1/2014 Commonwealth of Massachusetts
e CitylTown of North Andover
System Pumping Record
Farm 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 pr T eeS stem pumping using
Record form,
must be check
ubm�iited o
local Board of Health to determine the farm they us Y date in
the local Board of Health or other approving authority within 14 days from the pumping
accordance with 310 CMR 15.351.
A. Facility information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover Zip Code
use the return State
City/Town
key.
OQ2, System Owner:
a Name
Address(if different from location)
State Zip Code
Ci own
Telephone Number
B. Pumping record _ —
�! 2. Quantity Pumped: Gallons
1. Date of Pumping Date
Tight Tank F-1 Grease Trap
❑ g
3. Type of system: ❑ Cesspool(s) Se P tic Tank Ti
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes ❑ No If.yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: (1�jl
6. Syste ped By:
Vehicle License Number
wart's Se Ice
Compan
7. Location where contents were disposed: "
Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility
Date
System Pumping Record•Page
t5form4.doc•03/06
Commonwealth Of Massachusetts
U�yffown of North Andover
t m Pumping Rer
Form 4 DEP has provided this form for use by local Boards of Health. Other farms may be used, but the
motion must be substantially the same as that provided here. Before using this form, check with your
information in Retard must b submitted io
local Board of Health to determine the form they use. The System pumping date in
the local Board of Health or other app roving authority within 14 days from the p um n f
accordance with 310 CMR 15.351.
A. FacHity �nformation ti.
Important;When
1 System Location:
711ing out corms y
on the compuief,
...
a
use only the tab ! �
key to move your Address Ma
01886
cursor-do not North Andover State Zip Code
use the return City/Town
key.
2. System Owner:
Name
Address(if different r"rom location)
State — — Zip Code
CityfT own
Telephone Number
B. Pump�ng Record
2. Quantity Pumped: Gallons y
1. Date of Pumping pate
Tight`I ank ❑ Crease Trap
3. Type of system: E] Cesspool(s) J Septic Tank ❑ g
❑ Other (describe):
. es, was it cleaned? yes ❑ No
4. Effluent Tee Filter present? ❑ Yes E] I
No f y
5. Condition of System:
4
6. System Pumped By
Vehicle License Number
Name
Stewart's Septic Service
Company
7, Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Date
Signature of Hauler
Signature of Receiving Facility
Date
System Pumpinc
t5torm4.doc•03106
Commonwealth Of Massachusetts Y
I
v City/Town Of North Andover
System Pumping Record
Form 4
w DEP has provided this form for use by local Boards of Health. Other forms may be used, but the with
your
information must be substantially the same as that provided here. Before usiRngctr�fmust beesubmi ted o
local Board of Health to determine the form they use. The System Pumping
the local Board of Health or other approving authority within 14 days from the pumping,date in
accordance with 310 CM 15.351.
A. Facility information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab (
key to move your Address Ma 01886
cursor-do not North Andover Zip Code
use the return State
City/Town
key.
2. System
a :....
Owner
k,(w....m
Name
Address(if different from location)
State Zip Code
City[Town
Telephone Number
B. Pumping Reeerd
1. Date of Pumping Date 2. Quantity Pumped: Gallons --
d(
Grease Septic Tank ❑ Tight Tank Grease Trap
3. Type of system: ❑ Cesspool(s) E] p
❑ Other (describe):
4. Effluent Tee Filter present? El Yes ❑ No If.yes, was it cleaned? F-1 Yes ❑ No
5. Condition of System:
G&"f
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record-Page 1
t5form4.doc•03/06
Commonwealth Of Massachusetts
: x city/fown of North Andover
y � m Pumping e ord
Form 4
w DEP has provided his form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the that r using check
local Board of Health to determine the form they se The System Pumping Record must be submitted to
- date m
the local Board of Health or other approving authority within 14 days from the pumping,
accordance with 310 CM 15.351.
i
l;
A. Facility lnformatien °<° y 4 �, � 'J"
ii
important.:When
filling out forms 1. system y .....-
Location:
on the computer, r"'"
Irj
use only the tab „etc :3
key to move your Address Ma 01886
cursor-do not North Andover Zip Code
use the return State
C-r<,j[rown
key,
2. System Owner:
° Name
rzrmn
Address(if different from location)
State Zip Code
City/—i ovvn
' Telephone Number
B. Pumping Record
Gallons
2. Quantity Pumped:
1. Date of Pumping -date
3. Type of system: Tight Tank ❑ Grease Trap❑ Cesspool(s) Septic Tank ❑ 9
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If,yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record-Pag
t51orm4.doc-03/06
Commonwealth Of Massachusetts
= City/own of North Andover
System Ptimping Record
Farm 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 14 days P from pintghe Record must b pumping daze in
to
the local Board of Health or other approving authority
accordance with 310 CMR 15.351.
A. Facility lnfera ation
Important:When
1. Sy stem
filling out forms
on the computer, ca
r
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover Zip Code
use the return State
City/Town
key.
�
Q Owner:
'I
Y
2. System
Name
rnmn „
Address(if different from location)
State Zip Code
City/Town
Telephone Number
B. Pumping Record
2. Quantity Pumped: Gallons
1. Date of Pumping Date
Septic Tank ❑ Tight Tank ❑ Grease Trap
3. Type of system: E] E]Cesspool(s) P
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No Ifyes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
Systern Pumping Record-Page
t5form4.doc-03/06
Commonwealth Of Massa.chUse
� 7 ❑ityf own of North Andover
System Pump ing � �
;i
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 herBefore using Record emu t bees submitted °
local Board of Health to determine the form they use. The System p n date .s
the local Board of Health or other approving authority within 14 days from the pumps g
accordance with 310 CM 15.351.
A. Facility lnformation
important:When
System r Location:
filling out forms 1. t
on the computer, . p A
use only'he tab
key to move your Address Ma 01886
cursor-do not North Andover State Zip Code
use the return City/Town
key.
2. System Owner:
Name
Address(ir'difFerent from location)
State Zip Code
City i own
Telephone Number
B. Pumping Record
1, Date of Pumping 2. Quantity Pumped:
Date
3. Type of system:
❑ Cesspool(s) [� Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present. ❑ Yes ❑
No If.yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Date
Signature of Receiving Facility
Date
System Pumping Record-Pag
t5form4.doc 03/06
`
�
�
Commonwealth of Massachusetts
S
~ `yffown of North Andover
` m Pumping Recard
Form 4
nfu/ usebYoa| Boa»dsofHea¢�� utnerfonnsmaybeuaed. but the
DEphaspnov�edthisfo � fonn, check
with your
information mustbesubstonba\�thasamoeSthatpro«idedhere� 8efora
local Board of Health to determine the form they use. The System pumping Record must be submitted-Lo
e |uoa| Board of Health or other approving authority within 14 days from -the pump�ng,date in
�
�
accordance with 3i0CK8Ri5,351
A. Facility oxu0000^"=^^"~..
"lmpoqant When 1 System
�N�c��� "/
o n'he computer, ,~ ,)�
use only the tau
key to move your Address Ma 01886
ovmnr do not North Andover State zip code
� m
use the. u _
key. �
2. SystemOwner
VQ J-,cl k" C)
Name
Address(if different Irom location)
State Zip Code
_, i own
B. Pumping Record
2, Quantity Pumped: Gallons
1. Date of Pumping
Te|vpxonewvm�s
3. Type ~' `x~~m' E] pool(s) ^\ Septic Tank Tight Tank F� Grease Trap
E] Other (describe): --------�
4. Effluent Tee Filter present? Fl Yes Fl No .1f.yes.\masit aned? Fl Yea No |
�
5. Condition mfSystem:
& System Pumped
Vehicle License Number
Stewart's Septic Service
`
c�pany
7, Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
�
U
m= /
°y ~~'~~ '~---g Facility—
m
oyo�mPump ms Record'�
1.51onn4.doc03m6
Commonwealth of Massachusetts
C'tylTown 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 for check with y o to
ur
local Board of Health to determine the form they use, The System Pumping Record musm,t check
date in
the local Board of Health or other approving authority within 14 days from the pumping
accordance with 310 CMR 15-351.
A. Facift y �nformafion ?"4
important When
filling 1 System Location:
I out t forms
on I the computer,
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover State Zip Code
use the return CiLyfTown
key,
2. System Owner
k V
/
a Name
Address(if different from location)
State Zip Code
City/Town
' Telephone Number
B. Pumping Record Ayv,
1. Date of Pumping Date 2. Quantity Pumped: G211ons
Grease Trap
3. Type of system: E] Cesspool(s) Septic Tank ❑ Tight Tank El
❑ Other (describe):
Q. Effluent Tee Filter present? ❑ Yes ❑ No .1f.yes,I was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Fdifity
System Pumping Record-Page
t5form4,doc-03/06
❑� Commonwealth Of Massachusetts
= City/Town of North Andover
System Pumping Record
or
DEP has provided this form for use by local Boards of Health.lt Other forms r us a bes farm,but
check with your
information must be substantially the same as that proved Record must check ck with
submitted your
local Board of Health to determine the form they use. The System Pumping date in to
the local Board of Health or other approving authority within 14 days from the pumphng ,
accordance with 310 CMR 15.351.
A. Facility information
J
s
Important.When
filling out forms y ocatio
1. System L n:
on the computer,
use only the tab
key to move your Address 01 886
cursor-do not North Andover Ma
State Zip Code
use the return CityfTown
key.
2. System wOwner.
�:.m.
Name
rm� Address(if different from location)
State Zip Code
city/f own
Telephone Number
Be Pumping Record
2. Quantity Pumped: Gallons) r
1. Date of Pumping Date
Tight Tank Grease Trap
Septic Tank F] 9
3. Type of system: ❑ Cesspool(s) p
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If.yes was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
system Pumping Record-Page
t5form4.doc•03/06
Commonwealth of Massachusetts
City/Town of North Andover
4 System Pumping Record
Form 4
w 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 usiRngcho dfmu s check ubrni ted o
local Board of Health to determine the form they use. The System Pumping date in
the local Board of Health or other approving authority within 14 days from the pumping
accordance with 310 CMR 15.351.
A. Facility information
Important When ���W , i'„[k li
1 System Location:
g ”?
n1lin out Corms y
� ro
on the computer,
use only the tab
key to move your Address f(la 01886
cursor-do not North Andover Zip Code
use the return
City/Tawn State
key.
2, SystemµOwner:
ou Ple
a Name ....
Address(if different from location)
State Zip Code
Cityaown
' Telephone Number
B. Pumping Record s..l�.�
t
G
._
" — —�— 2. Quantity Pumped. aup n
1. Date of Pumping Date
Grease Trap
3. Type of system: El Cesspool(s) Septic Tank F1 Tight Tank ❑
❑ Other(describe):
4. Effluent Tee f=ilter present? ❑ Yes ❑ No if yes,I was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record•Page
t5form4.doc•03106
Commonwealth of Massachusetts
i
City/Town of North Andover �
a
System Pumping Record
Fom
DEP has provided this farm for use by local Boards of Health. Other forms may be used but the this information must be substantially the same as that provided iRecordfmust be submitted is
local Board of Health to determine the form they use, The Sy stem Pumping date in
the local Board of Health or other approving authority within 14 days from the pumpeng
accordance with 310 CMR 15.351.
A. Facility information
important:When
p 1 S
filling out.arms stem Location:Y
on the computer,
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover Zip Code
use the return State
City/Town
key.
..: l ..
OQ 2. System Owner:
Name
m= rye' I I
� Address(if different from location)
State Zip Code
City i own
Telephone Number
B. Pumping Record �
1. Date of Pumping pate 2. Quantity Pumped: Gallons
/Septic Tight Tank ❑ Grease Trap
Tank ❑ 9
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If,yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record-Pag(
t5form4.docc 03106
Commonwealth of Massachusetts
City/Town of North Andover
Syst m Pumping Record
e
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
substantially the same as that provided here. Before si th
u
ng is form, check with your
information must be sub e. The System Pumping Record must be submitted to
from
local Board of Health to determine the form they us s the umpi�ng date in
the local Board of Health or other approving authority within 14 day p
accordance with 310 CMR 15,351.
A. Facility lnformation
important:When
filling out forms System Location:
on I the computer,
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover State Zip Code
use the return cit own
key.
2. System Owner:
q
Name
Address(if different from location)
State Zip Code
Cityrf own
Telephone Number
B. Pumping Record
2. Quantity Pumped: Gallons
1. Date of Pumping -6ate
3. Type of system-. E] Cesspool(s) El Septic Tank R Tight Tank Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No Ifyes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Vehicle Lice ..Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record-Pag(
t5form4.doc-03/06
— .
^
^'
Commonwealth of Massachusetts
Cuy, : v."" ^ of North Andover
�
System Pump^ng Record |
Form 4
DEP has provided this form for use by local Boards of Health, Other forms may be used, but the
information informabonmust beuubstanb���the same ma that provided here. Before using rn�form, check �m�edio |
local Board of Health to determine the form they use. The System Pumping Record muu"*eis"° /
/uc�|oua| Board of Health oroth^'epprmv\nQ authority within 14 days from the pumping date //
accordance with 310CK8Ri5351
A. Fay.o"ouy u"""~°" ""`^^t~o^'
important:When
filling out forms 1 System L uanon
on the computer, �
use only the tab
key � �� ,/,`
�tom ��mr »�uas � o 01886
uv�o do no, North Andover � Zip Code �
use�eemm State �cit' own
key.
2 System Owner:
Name
Address(if different from location)
State Zip C"v=
city own
�i.ph�nemvmbe/
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: _c�_a_flons
3. Type of system'. E] Cesspool(s) E] Septic Tank F-I Tight Tank E] Grease Trap
El Other(describe): |
' |
4� Effluent Tee Fi�erpresent? El Yes E] No 1f yes,vvoe ¢cleaned? ^F� Yes �� No� ��
|
5 Condition ofSystem: �
�
8. System Pumped By:
Vehicle License Number
Name
Stewart's Septic Service
Company
7 Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Date~'y''~^~'~~Hauler
Date
Signature of Receiving Facility system Pump mg Record'pa8^ �
t5fonn4,uoc-03/06
�
Commonwealth Of Massachusetts
--- sty/Tow Of No Andov r i A 0 �1
yt o r
Form
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.
AA Facility Information
Important:When
filling out forms 1. System Location: , .
on the computer, •. z
C
use only the tab
key to move your Address
cursor-do not No Andover Ma
use the return _
key. City/Town — State Zip Code
2. System Owner:
Name
ienan
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping scar
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) a❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ 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:
,qIewartis.-Pre-treatment Plant, 20 So. Mill Bradford, Ma 01635
Sig 1r"store of klauler Date
Signs'
fine of Receiving Facility Date
t5farm4.doc 03!06 System Pumping Record•Page 1 of 1
Commonweal-th of Massachusetts
w CityrFown of No .Andover
System pay coy
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 1. System Location:
on the computer,
I w
p / { ,. ....,
use only the tab �.
key to move your Address
cursor-do not No Andover Ma
use the return
key. City/Town State Zip Code
2. System Owner: °
Name
mnnn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Dumping Record
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ 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, Ma 01835
Signatu of Hauler
,. Date
Signature of Re eiving Facility Date -
t5form4.doc°03/06 System Pumping Record.Page 1 of 1
_ Commonwealth Of Massachusetts
H W City/Town of No Andover
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 110 CMR 15.351.rapproving authority within 14 days
accordance with 3
A. Facility Information Cd
Important:When
p �.., t�1 @f AL f 'i DEPA� IN 41 L�
�.� q B 1�4V If L
filling out forms 1, System Location. 1NI"'1 tj N"181 t B
on the computer, fna w
use only the tab c
key to move your Address
cursor-do not No Andover Ma
use the return
key, City/Town State Zip Code
2. System Owner: ...,
Name
mawr
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Pumped:
p g Date 2. Quantit y Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. "_System Pumped-ay:
Name I y
Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's,rvPT-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature o auler i Date
Signature of Receiving Facility-. Date
t5form4.doc 03/06 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts
--u City/Town of NO Andover
System u 1n 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
CEIVED
A. Facility Information
important;When
filling out forms 1. System Location:
on
use only he tab 4 ICi"�
computer, t
y 08 ff fl dpiiupPNT
a f°fRr�iwi 41V k 9CR
key to move your Address ommrwaouuJi ' Ni! °: i
censor-do not Na Andover
use the return Ma _
key. City/Town State Zip Code
j 2. System Owner: f
Name
reaoti
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record _
��_a t eL 1. Date of Pumping 2. Quantity Pumped: Gailon�? u
s
3. Type of system: ❑ Cesspool(s) . Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: cd
6. S stem Pumped By
. . ( -CIII
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
ignat re Q#,i-ia�rlc�r�
Date
,Si nature�of Re"viceivirig 1aciiity pate
t5farm4.doc°63/06 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts'
❑ City/Town of No Andover
System use eerd
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 a in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When f7� Vw iiL I&ili I V I d tlBtf Po1
filling out forms 1. System Location: �� H l IliD 1w 81Tp,7iwu�l
on the computer, jz__ �
use only the tab
key to move your Address
cursor-do not No Andover Ma
use the return
key. City/Town State Zip Code
2. System Owner:
Name
move
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da e 2. Quantity Pumped: � .
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
• _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, Ma 01835
Sign
at w re,of :. _� _ Date
+gnature"Of Receiving F9dil V'- Date —
t5form4.doc 03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
-- City/Town of ISO 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 rMCEI
Important:When
filling out forms 1. System Location: c)R o
on the computer, - I
use only the tab
9i
key to move your Address
cursor-donot No Andover Ma IWu<M�. ,a Nara,om umowwww wrrt a„r+ruuwuamr9^yu rww;vrwwmw �
use the return
key. City/Town State Zip Code
2. System Owner: bV
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
6t _L L 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumpe ,By-
t_
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Sign ry ure, tYtHauler--
i
._ m,.., Date
ignature of Receiving Facility Date
t5fprm4.doc 03/06 System Pumping Record-Page 1 of 1
Commonwealth of Massaohusett
City/Town of North Andover
System Pumping Record
- Fora 4 ,
t
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 1. System Location:
on the computer,
use only the tab _-
(xil c' .
key to move your Address
cursor-do not N. Andover Ma _
use the return City/Town State Zip Code
key.
2. System Owner:
� Name - -- -- - —
ietran --
Address(if different from location)
City/Town - State - — Zip Code- —
Telephone Number
B. Pumping Record
1. Date of Pumping -- 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ---- —
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: w
6. System Pumped B :
r- r-_
,,
- -----------
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's P e-treatment Plant, 20 So. Mill Bradford, Ma 01835
ui natur of aule — —
_ g r Date
— ------ ------ --
~---- - ° Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts 1
- /Town of North Andover
I
City/Town Y i
System Pumping Record �1,,,Y I
a
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 w
filling out forms 1. System Location:
on the computer,
use only the tab --
key to move your Address
cursor-do not N. Andover Ma
use the return City/Town State Zip Code
key.
2. System Owner: ..
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
�.
1. Date of Pumping -- 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
�.a
6. . stem Pum ed By:
_- -
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart' Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
__.. .. Date
...,...w.. �na�e,of.� a�uer wm.,M..,
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of (North Andover
I'
System Pumping Record
`i� � i "C 1
s
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 Q)i
filling out forms 1. System Location: .
on the computer, „
use only the tab _
key to move your Address
cursor-do not N. Andover __ _ Ma
hey the return City/Town State Zi p Code
VQ 2. System Owner:
k
� Name -
etren
Address(if different from location) --
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping / 2. Quantity Pumped: '
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
�M
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company —
7. Location where contents were disposed:
ewart's Pre-treatm nt Plant, 20 So. Mill Bradford, Ma 01835
g. r Date
�of.�aul�r
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
- W City/Town of NORTH A�1ClOV R �il << w4,
System umpin ore! h
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, b"i k I
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER Ma _
use the return Cit /Town
Sta#e key. Zip Code
reb ,
2. System Owner:
Name
�ehann
Address(if different from location) -
City/Town State Zip Code
Telephone Number
B. Pumping Record
)
d V-
1. Date of Pumping � Quantity Pumped:
— 2. Quanti
Dato Gallons
3. Type of system: ❑ Cesspool(s) [°Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ 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, Ma 01835
uler:P
Date
f Ala
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts 1
City/Town of NORTH ANDOVER
Y
=
System Pumping Record
Form 4
A r im.u✓ mediudjp
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. S stem Location:
computer,on the
use only the tab '"��
key to move your -
cursor-do not NORTH ANDOVER Ma
use the return
key. City/Town State Zip Code
2. System Owner:
rab
Name ---
renrn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record _f
�t 2 ' �—,,f
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3, Type of system: ❑ Cesspool(s) i l k ❑ Tight Tank 7�Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
N 06 Vehicle License Number
ewart's-Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler' Date
Signature of Receiving Facjli y Date
t5form4.doc-03/06 < System Pumping Record>Page 1 of 1
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Commonwealth Of Massachusetts
-- City/Town of Forth Andover
{ yy �r J)pII
G i 1 4 4 I,
System Pumping cord i,,,,l
r;
Foram 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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab /"❑(�) 1 1 �0 c"') Aj1(''-_.
key to move your Address
cursor-do not North Andover Ma 01886
use the return Cityrfown State Zip Cade
key.
� j❑ 2. System Owner:
Name
rerwn �,
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 [2 Grease Trap
❑ Other(describe): -"
4. Effluent Tee Filter present? ❑ Yes ❑ No If.yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6
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, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
r
Commonwealth of Massachusetts
x
City/Town O•f North Andover
System Pumping Record Qaa.
Form 4 �l
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, ° ,w�.
use only the tab i
key to move your Address
cursor-do not North Andover Ma 01886
use the return City/Town State Zip Code
key.
J--� 2. System Owner:
Name
rntum
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record A 5660
1. Date of Pumping pate / 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): \
4• Effluent Tee Filter present? ❑ Yes ❑ No If.yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
lJ�J
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, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
�fl/ f
C,ornrnonwoalth of Massachusetts
City/1-own of North Andover
M
System Pumping Record
fi iill fi i /ir
"-fr
q
F �d I Form Form } ,
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 1. System Location:
on the computer,
use only the tab ////)y -
key to move your Address
cursor-do not North Andover Ma 01886
use the return City/Town State Zip Code
key.
2. System Owner:
Name
2tum
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
� � ���
1. Date of Pumping Date m 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) N, Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If.yes, was it clearied? ❑ Yes ❑ No
5. Condition of System: ,
6. System Pumped By:
7
l( X
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03106 System Pumping Record•Page 1 of 1
Commonwealth O'FIaah�aStkS a. a Y
_ City/Town of North Andover �
System Pumping Record AUG' ' 4 M H
Fcarrn 4 I'
DEP has provided this form for use by local Boards of Health. Other forms maybe used,"but'tho'��°'�
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 f orms System Location:
on the computer
use only the tab,
t p
key to move your Address
cursor-do not North Andover Ma 01886
use the return City/Town State Zip Code
key. p
2. System.Owner: 1�
� Name
rerun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
/
❑❑
f
/
Date
1. Date of Pumping 2. Quantity Pumped: ...., Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank I ' Grease Trap
❑ 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, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06
System Pumping Record•Page 1 of 1
c'.!r1w Aw!i way.w mw, r. wr r rwa>^:wwwr um
R ED
Commonwealth of Massachusetts
—_ ---� City/Town of North Andover
System Pumping oc rd
Form .4 '
, ww
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, ,
use only the tab <�.> I W) 116 >
key to move your Address
cursor-do not North Andover Ma 01886
use the return
key. City/Town State Zip Code
2. System Owner:
Name
rewn ,
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 Grease Trap
❑ 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, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
rllLKrth ,�y,rtrmIG010
Commonwealth Of Massachusetts
I
-- - C—ty/Town of North Andover o '
System Pumping d ❑�
Form.4 o GNU A" DavE.,r
ENT
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 frorn the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:When
filling out forms 1. System Location:
on the computer, .
use only the tab 35 d to//j 6 ilo
key to move your Address
cursor-do not North Andover Ma 01886
use the return
key. City/Town State Zip Code
2. System Owner:
ret+en
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping Date / ❑ 2. Quantity Pumped: o
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap
❑ 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 Servi e
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1