HomeMy WebLinkAboutSeptic Pumping Slip - 350 FOREST STREET 4/19/2016 Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forrh!maybe"6seld,'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 CM R 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 01886
use the return City/Town State -------- Zip Code ---------------
key.
2. System Owner:
VQ Z I�(..,)Qa
Name
tenon
Address(if different from location)
-----------------------
City/Town State Zip Code
Telephone Number
B. Pumping Record
6-15 / V . .........IFR
1. Date of Pumping Date 2. Quantity Pumped: ..Gallons j
3, Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank F-1 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
StewarVs_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
City/Town of _NORTH ANDOVER, MASSACHUSETTS
System in cord .
Form 4
DEP has provided this form for use by local Boards of H alth. nh� Byrne rl umpI Record must
be submitted to the local Board of Health or other appro Ing a2fitrlty.
A. Facility Information I4v t TI1" ""PART F T'
Important:
When filling out 1. System Location;
corn uter,use � l
arms on the -
only the tab key Address ,
to move your —
the- not
use th City/Town State Zip Code
use e retet urn P
key. , 2. System Owner;
C CA
Name -- —
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. hate of Pumping 10('Q patQ /to 2. Quantity Pumped: Gallons
3. :Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
Other(describe); ---
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes;was it cleaned? ❑ Yes ❑ No
5. Condition of System; ((
6. System Pumped B ;
erne
- Vehicle License Number
--
Company
7. Location where contents were disposed:
Signature f Haule r ate
http;//www.mass.gov/dep/water/approvals/t5forms.htm#Inspect
t5form4.docr 06/03 System Pumping Record-Page 1 of 1
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DEP,has provided this form for use by local Boards of Health. 7 e System Pumping Reco d must
be sub'mitted to the' local Board of Health or'other approving aut d�f't
f
Aa Facility information
�Lm ortnt '.
,:,When flung out 9.. System Locatlon
t use „
�•fp on
pr,tab C )l r
only y Address
to move your
cursor do not
CI /Town
use the return tY• .. State Zip Code
�eyr
2,`-, System Owner ,
"? Name
' Address(If different from location)
City/Town.,,,State
Cod
p e .
` Telephone Number
4` 9 Date of Pumping Date 2. Quantity Pumped; ` --
Gallons
3,' 'Type of system Cesspool(s) E2 Septic Tank ® Tight Tank
®' Other(descrlb )r
4 '
Effluent Tae Filter'present?.® Yes.D-N. If yes, was It cleaned? ® Yes (] No
+
rtt 'r ' r >J �Oondltion ofSystmi y,
0�/Y"""Cr�'
6 Sy Pumped By
' ame•.,'4' ,, x 5t°,�k rt:;
Vehicle LlcenaeNumber
/hWI
mp+' +/,
4', 7, Loca))tlpn whore contents'wprq dloposed;
Its
k Signature of Hauler ,� . . Date
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t5forrrol.doi-, 0103 System Pumping Record - Page 1 of t
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