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TOWN 1"NO$TH ANDOVER
SYSTEM PLWINO RECORD
DATE
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
f ,
DATE OF PUMPTN QUAN TTTY'PUMPED C'
CESSPOOL NO
YES . r SEPTIC TANK NO
YES
NATURE OF SERVICE, RQCEMERQENCY
OBSERVATIONS:-
GOOD coNT7i'ProN 1 `"' ' . ULT TO COVER
I-EVAVY OREASE � BAFFLES IN LACE
ROOTS LEACIVIELD RVNBACK
EXCMWE SOLIDS , 'FLOODED
SOLID ARRYOVE OTHER EXPLAIN ;
SYSTEM PUMPED 13Y
COMMENTS;
CONTENTS TRANSFERRED TO
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER chi ADDRESS SYSTEM LOCATION
(example:e: e t front o f house)
_ w
DATE OF PUMPING �: ° � '' (QUANTITY PUMPED � "GALLONS
y_
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS;
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: µ
Commonwealth of Pdassachuselts
pI
Massachusetts
ygtem Omier Systetu Localiort
Date of Pumping: �� � & Quaittily Pumped: _._ �alloots
w.�, - (_ l S I,::1 Yes
Cesspool: No Yes Septic " 'auk: I�lc�
System Pumped by; Fegrejart Seereoi4w License
Contents translerrred to : Greater jaw(evice Sanitary District
Dale: ------ �_ ___ �_ Ittspeclor _ ��
Commonwealth of Massachusetts
W City/Town of No.Andov r
-- —
System Pumping r
Farm 4
DEP has provided this form for use by local Boards of Health. Other forms may ,§ ,,but the,,,,
information must be substantially the same as that provided here. Before usin this frho-�w�t you
local Board of Health to determine the form they use. The System Pumping R cord must be subml ted t
the local Board of Health or other approving authority within 14 days from the umpipg,, a�e( n, �
accordance with 310 CMR 15.351. '4` °
?I �i Itf A kt A G'i 411 R fi
A. Facility Information
Important:
When filling out 1. System oca#Ion:
forms the ❑
computer, use
only the tab key Address
to move your No.Andover Ma 01845
cursor-do not ------- -- --------
use the return City/Town State Zip Code
key.
2. System Owner:
Av
�� - --- —
VIVO
------- -------------------------------
Name
8h4 Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Regard
I �
1. Date of Pumping 2. Quantity Pumped: `
Date Gallons
3. Type of system: ❑ Cesspool(s) 2� 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. S m , Limped By; -
------------- ---------------------------------------- ----- -------
N69 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 Receivi Facility Date
t5form4.docc 03/06 System Pumping Record-Page 1 of 1
VED
Z:-\ Commonwealth of Massachusetts
- City/Town Of North Andover
fir w (
System umpi Record
4
TOtidI() �' R1 rAI ,0w I Farm 4
t)I:;�t lhdEtE f �'�i fI�V 4Jiu
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
key to move your Address
cursor-do not North Andover Ma
use the return --- — -- - -
key. Cityfrown State Zip Code
2. System Owner: w, _
tab
Name
iehnn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping cor
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:
t
m. �6 e
6. " tem Pum p Y
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stews sPre-treatment Plant, 20
So Mill Bradford Ma 01835
-- g cure oAeiF,
le�- - ..�.. Date ,
Signatures ing Facility Date
t5form4.doc<03/06 System Pumping Record •Page 1 of 1