HomeMy WebLinkAboutSeptic Pumping Slip - 444 SALEM STREET 3/4/2016 L\ Commonwealth of Massachusetts
City/Town of North Andover
Form Astem Pumping
OW
Form -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 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 1. S y stem ca�
ts computer,ue only the tab
V.
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
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) []"'S' eptic 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: f
6. System Pumped :
me 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
m
Si r -.�-�._.. . ... ..w —Date--_
nature of �
� g
e of Raaf�g""Fac - — --- -- - - -- — - ---
ility Date
t5 rr ' drob d /06 System Pumping Record-Page 1 of 1
Commonwealth Of Massachusetts
— u City/Town of North Andover
a - System i r
4 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 uslnq this form, check with your
local Board of Health to determine the form they use. The System Pupirigod rr� s"u � fitted to
the local Board of Health or other approving authority within 14 days f m the pumping a e in
accordance with 310 CMR 15.351.
A. Facility Information t'Ow NN
Important:
filling When y ,. ,
forms on the
1. System LOCa 1011- � ` � � ��
computer, use - - - - - -- —
only the tab key Address
to move your North Anover Ma — 01810 —
cursor-do not --- -- ------—use the return City/Town State Zip Code
key. 2" System Owner:
Qmb
— —--- -
Name ----- - ----
° .
eh� Address(if different fron location)
City/Town — State Zip Code ----
Telephone Number
B. Pumping Record
1. Date of Pumping -'❑ 2. Quantity Pumped: Gallons
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. _Sy
fe
Pump d B .
�� .. _ - -
_ _
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
Sig r o H uler Date
n ure o eceiv' g Facility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
. ar�m®nwlt'h of Massachusetts �
r City/Town of NORTH ANDOVER SS"ET t
r
System Umping Record
Form 4 d,f c, d of j
Ct p Pumping EP has provided this form for use by local Boards of Health. Th � stern Pum �in Record mu,,
Y .
be submitted to the local Board of Health or other approving author f p g
A. Facility Informati®n
Important;
__._
When fillip out System Location:
forms the
computer, use y � ` °•W
only the tab key A ddress
to move your
cursor-do not — .---..—_._—_�_-_._.__..�_ .
use the return Clty/Town State - - —
Zip p Code
key. 2, System Owner;
I&]
Name
Addresa(If different from location) --
ity/Town State — ------.__
Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping _
Date - - 2, Quantity Pumped;
Gallons
Type of system, ® Cesspool(s) Septic Tank
❑ Tight Tank
,... ...,, ❑ Other(describe); _..___..
4, Effluent Tee Filter present? ❑ Yes "No if yes, was it cleaned? ❑ Yes ❑ No
5, Condition of System:
...-611_.ASyem Pumped Ely;
_.. .._
Vehicle License Number
(5t Aq
Company -
7, Location where contents were disposed;
Si *atureau Date
http://www,miss,gov/dep/water/ provals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record - Page t of