HomeMy WebLinkAboutSeptic Pumping Slip - 239 GRANVILLE LANE 3/7/2016 h.
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 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, C,
use only the tab Y Z' /""1' 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:
W4016
rerun ,�{Rr,
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Reco rd
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
Commonwealth Of Massachusetts
n x ity/Town Of NORTH ANDOVER
System ,
a
Pumping r
Fortin 4
,e
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 Loca
on the computer,
use only the tab
----- ------- - -
key to move your Address ------
-
cursor-do not NORTH ANDOVER Ma
use the return ---------- — -----------------
key. City/Town State Zip Code
2. System Owner:
Name
retim
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ecr
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 P.re-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Haul' , Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record.Page 1 of 1
Commonwealth Of Massachusetts
City/Town of
Pumping I System
Form
DFP 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.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left%�.Ig sides(jf_ me,Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner: _
F�
Name AUG
Address(if different from location) I;"' n I R
City/Town State -- Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Qua City Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) � eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es Cl No If yes, was it cleaned? ❑- es"❑ No
5. Condition i f Sys ern:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc tion where contents were disposed:
t
Lowell Waste Water
�.
Sign to a Haule Date
t5form4.doo>06/03 System Pumping Record•Page 1 of 1