HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 4/11/2016 commonwealth of M aSsrachusetts
'�y/Town of NbrL Ar�c�c�ver
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Heak,h. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this farm, check u
local Board of Health to determine the farm they use. The System Pumping Record must be subn
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facifityy �nformatilon
Important:When
filling out forms 1. System Location:
on the computer, .. +, '
use only the tab -5"-d V W I I (Q w
key to move your Address
cursor-do not North Andover
usethe return -- __..._.._.......... ._....... . ......... _ _...._.__.......__.,....._. - ---
key, City/Town state, , Zip Code
OkA2. System Owner:
_ IC e- 4y
_..._._. ._.
Name
Address(if dif ferent from location)
--.- ._...._................ ..._, .. - - - ------------
C'r'iyrown State Zip Code
Telephone Number _.._.._.__.__.
B. Pumping Record
&600
1. Date of Pumping -•--,..----.--.____........ ......... 2. Quantity Pumped: - —
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Tr
❑ Other(describe): ----__:....: ..__._..._...__..._..
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: r
6. System Pumped By:
are 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 _°_-_- - --._..._ _._.....__..—._.....
Oate
_ ..
ignature of Receiving Facilr`y -.._...,_...._.... ..,......._._., . . . ......_.._
Oate
t5form4.doc-03/06
System Pumping Record-Page
• W�Ury�n ww�rchl HV x IA� IG I�Ilmu ••
Commonweafth ®f �dassachusetts
City/ vin Of North Andover
System PUMpp ng Record 0-- 0ur,vER
Form 4 HEM (I I
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 A
local Board of Health to determine the form they use. The System Pumping Record must be subn
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. FacHity Wormation
Important:When
filling out forms 1. System Location:
on the computer,
use only the'ab ,w°' ❑— 1 (� dl n j a —
key to move your Address _. ...__..__._..._._...._... ,.. _..._.._.—_—_
cursor-do not
use the return North Andover
key. ity/Town _ -.....,._.. _...---
y State, Zip Code
2, System Owner:
601 � e- d
Name _ .._..... .. .....__.....-------.._..---•—---•--
Address(ifdrrrerentfromlocation) •••- ...__..._.. ._._.___...._._._._.__..._.._.__._______—._
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - _---........ ......._ 2, Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Tr
❑ Other(describe); — __._....__..,_..._.. _..__.... . .
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
CA C/
6. System Pumped By: /f
Vehicle License Number —
Stewart's Septic Service
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler — -- -- . ----__.... _
' Oate
Signature of Receiving Facility
Date
,5'om4.doc-03/06
Svstem Pumping Record-Page
Commonwealth Of Massachusetts
�- ❑ y❑Owes Of Nbrih 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 vA
local Board of Health to determine the form they use. The System Pumping Record must be subn
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Faci ty Wormation
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab N I '
key to move your Address --_._. _......._...___-.._.___.__.. .. __._
cursor-do not North Andover
use the return
key. City/Town -----_..,_.._.......
State., , Zip Code
2. Sy z Owner:
/4_ e—
Name __ .._ .... .. ..
Address(if�diffferent from location) —
Cityrown ---_._. ..._...,.....,. ..
State Zip Code
Telephone Number
B. Pumping Record
1• Date of Pumping - ? ... ,_..
rate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank fight Tank ❑ Grease Tr
❑ Other(describe): ---
4. Effluent Tee Filter present? ❑ Yes No !r` es, was It cleaned? Y
Y e ❑ es ❑ No
5. Condition of System:
6. System P ed By:
Nam —==�—- -
Vehicle License Number
_Stewart's Septic Service
Company —..._..,.. ......_ .
7. Location where contents were disposed:
Stewart' e-tr ent Plant, 20 So, Mill Bradford, Ma 01835
ignature of Hauler
Signature of Receiv ng Face,
Date ..... .. ...._.._
t5 om4.doc-03/06
Svstem Pumping Record-Page