HomeMy WebLinkAboutSeptic Pumping Slip - 915 JOHNSON STREET 4/7/2015 Commonwealth of Ma,�sachusetts
_ x City/Town of North Andover
System Pumping r
- 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 15351.
A. Facility Information ----
Important:When RE c .D
filling out forms 1. System Location:
on the computer,
use only the tab u�n�
key to move your Address
cursor-do not North Andover ail Af_I use the return — -------- -------- _.
key. City/Town State Zip Code
2. System Owner: ®t
lab �R
Name
icmm
Address(if different from location)
— ---- --
City/Town State Zip Code
Telephone Number
B. Pumping ec rd
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: 0-0,0-
System Pumped 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
------- -- --- -- - - ---------- -------
Signature of Hauler Date
Signature of Receiving Facility Date
- -------- _.._
t5form4.doc>03/06 System Pumping Record^Page 1 of 1
Commonwealth It tts
City/Town of
Pumping System `
Form
oO rTh &'vit)t VE&l'"
[ABP has provided this form for use by local Boards of Heal 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
nt;
en filling out
nsonrhe 1. Syste o�/tlo
1 the tab key Address
nove your Forth Andover ma 01886
sor-do not City/Town State Zip Code
the return
2. System Owner;
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Gate of Pumping Date 2. Quantity Pumped; Gallons �
3. Type of system: Cesspool(s) ®ueptic 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.,w_ stem Pum e
Name Vehicle License Number
Stewart Septic Service
Company
7. Location where contents were disposed:
"-""S warts re eatment Plant 20 So. Mill St Bradford Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
amA.doc®03/06 System Pumping Record•Page 1 of 1
a�
r
RECEIVED a ,.
SOWN OF NOR71-1 ANDOVER
HEALTH DEPARTMENT
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