HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 1/1/2015 Commonwealth of Massachusetts
City/Town of Borth Andover
r
System u6 Record
Form 4
J�M
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: ` U� C i E I i�,!�
on the computer, nw
use only the tab ------
key to move your Address �,f�. ❑°) �
cursor-do not North Andover
use the return City/Town — ------ - -- State Tov 11
key.
i iC..lJe.,i i-i Lalkl l hid"N?l.N l
2. System Owner:
rob
----- -- — ------- ` ' — -- -- -- -
Name
eum
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping cor
ic
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 Purn
— 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
IL
Commonwealth lth of M chusetts
--- -- x 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 Rec u ,b�� mitted to
the local Board of Health or other approving authority within 14 days from the pumping datd 1h�"
accordance with 310 CMR 15.351.
A. Facility Information 1 C)V; MO I I i A iD Vf:R
pfl./L (fIM i IAJ kl9'J41,
Important:When
filling out forms 1. System Location:
on the computer, t `
use only the tab V._1-_ 1 ✓` __ _----3
key to move your Address
cursor-do not North Andover
use the return ----- --
key. City/Town State Zip Code
2. System Owner: -Sov- -------
tab
Name
renm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ecr -
- - -_ 1% _
1. Date of Pumping Date 2. Quantity Pumped: Gad ons -
3. Type of system: ❑ Cesspool(s) E�Xeptic 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: -o ocf--------- ------
&--Sys"�em umpe�� . •-�
_ -�
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
Commonwealth of Massachusetts
City/Town ®f North Andover
System Pumping
Form 4
DEP has provided this form for use by local Boards of Health. Other fonds 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 Purnping R c rd must be submitted to
the local Board of Health or other approving authority within 14 days from thetatx �� c
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location: a
on the computer, `(
use only the tab 6 41 ✓
key to move your Address
cursor-do not North Andover
use the return – ___....._—__ ___
key. City/Town State Zip Code
2. System Owner:
tab
- _-
Name -- —------
remm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ec®rd 5/1 - D I del
1. Date of Pumping --- _ — 2. Quantity Pumped: -
Date Gallons
1 Type of system: ❑ Cesspool(s) 1k ❑ Tight Tank [j?/Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
— -- ._ -— — - -
0 J11 p _
6. System P B._____ . 1
Name Vehicle License Number
Stewart's rvice
pany – -
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
Commonwealth ®f Massachusetts
City/Town ®f North Andover
n
a w System Pumping Record
e�
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: UU
on the computer, d�b
use only the tab
key to move your Address
cursor-do not North Andover
use the return — -- -_
key.
City/Town State Zip Code
2. System Owner:
q
Name
rerun
Address(if different from location) a _�
City/Town State L�LJZJP"�U d❑t����
Telephone Number
B. Pumping ecor
1. Date of Pumping Date A5- 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:
ocdr
6. Syste
ere° Vehicle License Number
ewart s Septic Service
------------------------ ---------
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01£335
Signature of Hauler Date
-- ---- ------ -- -- - ---
Signature of Receiving Facility Date
t5form4.doc^03/06 System Pumping Record>Page 1 of 1
Commonwealth of Massachusetts
City/Town of North Andover
System nn
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.
R( ,r n V WC,r,
A. Facility Information A '[ I x(115
Important:When
filling out forms 1. System Location: w I:"� �f�! i4 P ICJi?. i t fl')OVU�,,
on the computer, �(� ii,w, L i L, :I i l �u`��-td
use only the tab lJ
key to move your Address
cursor-do not North Andover
use the return
key. City/Town State Zip Code
VQ 2, System Owner:
Name
iehun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ecor
1. Date of Pumping _ - ! Gallons
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: rv:\0
r
- --------- ------ ------- . .. - .—.
6;ewa;rt's Pumped
Vehicle License Number
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
RECEIVED
a�, Commonwealth of Massachusetts
_� ❑i' /�ov�rr� of �Nc��.h Andover G����'
'hem Pumping record uOVVV,4kD-
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 using this form,,check with your
Th
local Board of Health to determine the form they use. e System Pumping Record must be submiUed 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
Suing out forms 1. System Location: t
on the computer,
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.
. 0 2. Sys-Lem em Owner:
C
Name
Q rmm=
Address(if different rr"rom location)
State Zip Code
Cityrown
Telephone Number
B Pumping record
Quantity Pumped: Gallons
1. Date of Pumping Date
Tight Tank Grease Trap
Cesspool(s) ❑ 9
. 3. Type of system: E] ❑
Septic Tank
❑ Other(describe):
4. Effluent Tee Filter present. ❑
Yes ❑ No .If.yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
S ierr 'umpe y.. .
�`'„,,.�w°"" ..� .M. ......�........�... .......-.. ....,•Vehicle License Number
".. ' ' tewart's Septic Service
": ". ................ 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
EC EIVE
commonwealth of Massachusetts
IR ME NO ❑ityf own Of North Andover
' pump
e�a Record ili 111 pr.l� b c
` T
Form.A
w„ t
be used, but the
DEP has provided this form for use by local Boards of Health. Other forms may your
information must be substantially the same as that provided here. Before using this 'must check withed o
local Board of Health to determine the f they use, The System Pumping 9 date in
the local Board of Health or other approving authority within 14 days from the pumping,,
accordance with 310 CM 15.351.
�. Facility information
Important When
i stem Location:
1. S Iling out forms Y
on the computer,
use only the tab
key to move your Address 01886
cursor-do not Ma
North Andover State Zip Code
use the return City/Town
key.
�
� 2. System Owner:
c
Name
Address(if dir"erent from location)
State Zip Code
Cityrown
' Telephone Number
B. Pumping Record �..
e
Quantity Pumped: Gallons
1. Date of Pumping ate
Grease Trap
3. Type of system: E] Ti ht Tank Cesspool(s) Septic Tank ❑ g
❑ Other (describe):
4. Effluent Tee f=ilter present? ❑ Yes ❑ No
.If.yes, was it cleaned? El Yes ❑ No
5. Condition of System:
6. System Pumped By:
„..
i�Yame. rv.��.Y
Vehicle License Number
Septic Service
.,r
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 RECEIVED
: s City/Town of North Andover
;stem Pump ng Record i°(1��fitCC 01ANDOVER
€=orate 4
w DEP has provided this form for use by local Boards of Health. Other Before using besused, b heck with your
information must be substantially the same as that prove Record mustch submitted your
local Board of Health to determine the farm 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.
�. Facility 6nformation
important When m
System stem Location:
filling out forms 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
own
key,
key.
c 2. System Owner:
R)a
Name
� Address(if different from location)
State Zip Code
City i own
' Telephone Number
B. Pumping Record
5 1. Date of Pumping pate 2. Quantity Pumped: aeons
Tight Tank ❑ Grease Trap
tic Tank g
3. Type of system: E] Cesspool(s) Se F-1 p
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes ❑ Na
]f yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
('91�L
6. System Pur . By:
Vehicle License Number
� N
e
� art's-"Septic Service
o7ripany
7. L
"ion "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
=M� CityfTown of North Andover
System Pumping Record
Form 4,w DEP has provided this farm for use by local Boards of Health. Other forms may be used, but the
vided here. Before
information must be substantially the same as that pro slRecord must be check
ubmitted 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 15351.
A. Facility �nformafion
Important When
Y
1. System Location:
filling out farms `
on the computer,
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover State Zip Code
use the return CityfTown
key.
VQ 2. System Owner: �P
Name C
Address(if different from location)
State Zip Code
c'rtyrown
Telephone Number
B. Pumping Record
2. Quantity Pumped: Gallons
1. Date of Pumping Dat
�o
❑ Tight Tank ❑ Grease Trap
9
3. Type of system: E] Veptic Tank Cesspool(S)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No if.yes, was it clearied? ❑ Yes ❑ No
5. Condition of System:
d
6. System Pumped By:
Vehicle License Number
Name
Septic Se ce
pany
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Date
i a ure of Hauler
Signature of Receiving Facility
Date
System Pumping Record-Page 1
t5form4.doc•03/06
S°, Commonwealth of Massachusetts
City/Town of North Andover
a YStern Pumping Record ul the
DEP has provided this form for use by
same as that provided here. Before Befo e us ng this form,,bcheck with your
information must be substantially Record must be submitted to
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
;fling out forms 1. System Location:
on the computer, 10 °
use only the tab 35 1
key to move your Address 01886
cursor-do not Ma
North Andover State zip code
use the return City/Town
key.
&I 2. System Owner: �
Name
Address(if different from location)
State zip Code
City/T own
Telephone Number
�. Pumping Record 000—
2. Quantity Pumped: Gallons
t � 1. Date of Pumping Dat
v F Grease Trap
Cesspool(s) Septic Tank ❑ Tight Tank ❑
ff 3. Type of system: ❑
r
t ❑ Other (describe): .
4. Effluent Tee Filter present? ❑ Yes ❑ No
If.yes, was it cleaned? ❑ Yes ❑ No ,
5. Condition of System: 0
6. System Pumped By:
Vehicle License Number
�Stew _Septic Service
mpany
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
S°, Commonwealth of Massachusetts
CitylTown of North Andover
p stem Pump�ng Record
Form 4
w DEP has provided this farm for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here.
Be'
umping IRecard'must be submitted o
local Board of Health to determine the form they use. The Sy 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 lnformation
Important:When
System stem Location:
Slung out forms Y
on'he computer,
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover Zip Code
use the return State
c', own
key.
VQ 2. System Owner:
t 161 Name
Address(if different from location)
State Zip Code
cityrown
' Telephone Number
6. pumping Record _
2. Quantity Pumped: Ga orb
0 1. Date of Pumping Da e
Grease Trap
� Cesspools Septic Tank ❑ Tight Tank ❑
,�,
3. Type of system: ❑ )
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ Na
If.yes, was it cleaned? ❑ Yes ❑ NO
5. Condition of System:
mid-
6. System Pumped By:
Vehicle License Number
r9H s Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Date
Signature of Receiving Facility
Date
System Pumping Record-Page 1
t5farm4.doc 03/06
Commonwealth of Massachusetts
4 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
must be substantially the same as that provided here. Before using th to L
iniormation must be submitted
local Board of Health to determine the form they use. The System Pumping um in date in
the local Board of Health or other approving authority within 14 days from the p p 9
accordance with 310 CM 15.351.
A. Facility lnformation
important When
1. System Location:
Suing out forms Y
on the computer, g
use only the tab
key to move your Address Ma zip code
cursor-do not North Andover State Zip Co
use the return C�ity/Town
key.
VQ 2. System Owner
Name
Address if different from location)
State Zip Code
City/T own
Telephone Number
B. Pumping Record
2. Quantity Pumped: l
I. Date of Pumping Date
,t�( � Tight Tank ❑ Grease Trap
Cesspool(s) Septic Tank ❑ g
3. Type of system: ❑
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
If.yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: -Cl .
6. System Pumped By:
Vehicle License Number
N
Stew ervice
Company `'-
�- ~ ocation 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 Pumping Record-Page 1
t5form4.doc-03/06
Commonwealth of Massachusetts
: 7 CitylTown Of North Andover
System Pumping Record
Farm.4
w4 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 herPumping IRecord'musfibe submitted o
local Board of Health to determine the form they use. The System p 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, mmry
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 caner:
Name ��
ncn end I 8
� Address(if different r'rom location)
State Zip Code
City/Town
Telephone Number
B. Pumping Record
2. Quantity Pumped: Gallons
1. Date of Pumping Date
Tight Tank E] Grease Trap
❑ 9
3. Type of system: ❑ Cesspool(s) E] Se Septic Tank Ti
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
]f yes, was it clearied? ❑ Yes ❑ No
5. Condition of System:
6. System Pu!pp6'd B ,,.°.'°
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 Pumping Record Page 1
t5form4.doc•03/06
Commonwealth of Massachusetts
CityrTown of North Andover
-- o
System pumping Record
Form 4 forms may be used, but the
DEP has provided this form for use by local Boards of Health. Other
local Board information must be substantially the same as that provided here. Before usiRecord must be submitted to
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
filling out forms 1• System Location:
on the computer, Sk
use only the tab
key to move your Address Ma zip code
cursor-do not North Andover State Zip Co
use the return City/Town
key.
2. System Owner:
4 Name
rmmJry
Address(if different from location)
\ State Zip Code
City/Tow'n
Telephone Number
B. pumping Record
2. Quantity Pumped: Gallons
1. date of Pumping Date
Tight Tank F1 Grease Trap
3. Type of system: ❑
Cesspools) E] Septic Tank ❑ Ti 9
❑ Other(describe):
If. es, was it cleaned? ❑ Yes ❑ Na
4. Effluent Tee Filter present? E] Yes ❑ No y
5. Condition of System:
Pumped B ,m,,,. ..,.. ..
6, System y-. ,• °
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
Date
Signature of Receiving Facility
System Pumping Record-Page 1
t5form4.doc-03/06
Commonwealth Of Massachusetts
❑ifyffown of North Andover
-- : neon Record
Form.4
w DEP has provided this form for use by local Boards r Health. et B forms e using his form,oche k with your
information must be substantially the same as that provided her i Record must be submitted to
local Board of Health to determine the form they use. The System Pumping in date in
the local Board of Health or other approving authority within 14 days from the pump g
accordance with 310 CMR 15,351.
A. Facility information
important when
filling out forms 1. System Location:
A 1-j3
on the computer,
use only'he tab
key to move your Address Ma 01886
cursor-do not North Andover State Zip Code
use the return CPyl1 own
key.
2. System Owner:
a Name
Address(if different from location)
State Zip Code
City/T own
Telephone Number
B. Pumping Record d OW
f 2. Quantity Pumped: Gauons
1. Date of Pumping Date
Septic Tank Se ht Tank Grease Trap
❑ Tight
V. 3. Type of system: E] Cesspool(s) ❑ p
❑ Other (describe):
4. Effluent Tee Filter present. ❑
Yes ❑ No if.yes,`was it cleahed? ❑ Yes ❑ No
ffl
5. Condition of System:
6. System°Pumped B
Vehicle License Number
mart'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 Pumping Record Page
45orm4.doc-03/06
Commonwealth of Massachusetts
7 City/"Town of forth Andover
S-yshem Pump;ng R ecord
Form 4
DEP has provided this form for use by local Boards of provided h Ot Before using hers form,but
k with your
information must be substantially the same as that pra The System Y Pumping Record must be submitted to
local Board of Health to determine the form they use.
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 lnfa>I ration
important When
1. S stem Location:
tilling out forms Y
on the computer,
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:
U3 !
° Name
� Address(if different from location)
State Zip Code
City i own
Telephone Number
B. Pumping Record
BUY&2. Quantity Pumped: Gallons _
1. Date of Pumping Date
Tight Tank Grease Trap
Se tic Tank g
3. Type of system: E] Cesspoal(s) P E]
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
wart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Date
gnatur uler
Signature of Receiving Facility
Date
System Pumping Record•Page
t5form4.doc-03/06
Commonwealth Of Massachusetts
=
City/Town of North Andover
System UM �n Record
Form
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the 'h your
information must be substantially the same as that provided here. Befreusing Rard form,
must be submitted 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 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 State Zip code
use the return cityfTown
key.
2. System Owner.
re5 a
Name
rzun „
Address(if different from location)
State Zip Code
cityf-iown
Telephone Number
B. lumping Record r —
I / 2. Quantity Pumped: Gallons
Date of Pumping Date
l t Tight ht Tank E] Grease Trap
3. Type of system. ❑ Cesspoal(s) Septic Tank ❑ g
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it clearied? ❑ Yes ❑ No
5. Condition of System: .J r'�
� d -
6. System°Pumped By:
Vehicle License Number
Stewart's Septic Service
Gompany
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
Date
,, ,_ gnature of Hauler
Date
Signature of Receiving Facility
System Pumping Record•Page
t5form4.doc•03/06
Commonwealth of Massachusetts
: 7 City/Town Of North Andover
System pumping Record
Form 4
�y 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 co dfmust check
submitted r
local Board of Health to determine the form they use. The System p date in
the local Board of Health or other approving authority within 14 days from the pumping,
accordance with 310 CM 15.351.
R. Facility information
Important:When
Suing out forms 1. System Location:
on the computer,
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.
_0Q 2. System Owner: &uA(
a Name
Address(if different from location)
State Zip Code
City/Towh
( � Telephone Number
�. B. pumping Record
66a)
2. Quantity Pumped: Gallons
1. Date of Pumping Date
Ti ht Tank ❑ Grease Trap
3. Type of system: ❑ Cesspool(s) C Septic Tank ❑ 9
❑ Other(describe);
. ❑
4. Effluent Tee Filter present? ❑ Yes E] IfY es, was it cleaned? Yes E] No
Na
5. Condition of System:
__P d
6. System Pumped By:
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
Date
Signature of Hauler
Signature of Receiving Facility
Date
System Pumping Record•Page 1
t5form4.doc•03/06