HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 6/6/2016 Commonwealth of Ma,,�sachusefts
City/Town Of North Andover 91515TH,f
System Pumpin 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 wit
local Board of Health to determine the form they use. The System Pumping Record must be submi
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 Wormation
Important:When
filling outforms 1. System Location:
on the computer, ❑°
use only'he tab �
key to move your Address -- ----- -----
cursor-do not N
use the return North Andover
key. C'rty/Town
State Zip Code
2. System Owner
v
Name __._._-. -- - --- ------
_..—. ....
. ._...........-.._ ....,
Address(if different from tocation) •• -_...._. .__._._...._.___._.__._.__._..___.___..__..—_
City/I own ._., _
State Zip Code
Telephone Number _.._._.__.
B. Pumping ec'ord
I. Date of Pumping ,t. � ...,._ .., 2 Quantity Pumped: '� ^ --
Gallons
3. Type of system: ❑ Cesspool(s) ❑ eptic Tank ❑ Tight Tank ❑ Grease Tra
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ "es ❑ No
5. Condition of System.
6 Syster>� _.. ...._
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 --
,5 orm4.doc•03/06
System Pumping Record-Page
C❑monwealth Of Massachusetts
ry Ciiy/Town Of Nartth Andover
.T
System Pumping Record s 0 r °
f �b"tfN �9 �
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 wii
local Board of Health to determine the form they use. The System Pumping Record must be submi
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
�. Facility Wormation
Important:When
filling out forms 1. System Location:
on the computer, f
use only the tab
key to move your Address -- —
use cursor
the-do not
Noah Andover
use the return
key. C'rty/Town
State ,y Zip Code
2. System Owner:
Name — —.._.. .._......__ .._..... __._._..__._
yew,
Address(if ifferent from location) —
ity�own _t --.._._.._..___—.
State —-----_._. Zip C_ode
Telephone Number
B. Pumping Record
1. Date of Pumping �"� �. � L_r�,
Date - 2. Quantity Dumped:
Gallons
3. Type of system: ❑ Cesspool(s) [ /Septic Tank ❑ Tight Tank
g El Grease Tra
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
-• Pumped. By
� tern
'System
Name
_Stewart's Septic Service Vehicle License Number
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 Facilty
Date --
t5form4.doc-03/06
System Pumping Record-Page i
Commonwealth Of Nlassachusetts
❑"- /TO
.s
System Pumping Record
Form'4 TOWN N,
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 wit
local Board of Health to determine the form they use. The System Pumping Record must be submi
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
fining outforms 1. System Location:
on the computer, a
use only'he tab �key to move your Address
cursor-do not
use the return North Andover
key, City/Town
State Zip Code —.
2. System Owner:
m ,
Name
Address(if different from location)"
State Zip Code
Telephone Number - — _---
B. Pumping Record
1. Date of Pumping
date . "antity Pumped; Gallons
3. Type of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank
9 El Grease Tra
❑ Other(describe): - - _.....__..._.._.. - -....._ .
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ Nc
5. Condition of System:
6. System,
"µ �N�ri
S Septic Service .,. ._ Vehicle License Number
Ste
p'
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 . . . ......_.._
k5fom4.doc•03/06
System Pumping Record•Page
Commonwealth of Ma,�sachusetts
❑itty/Town Of North Andover
System Pumping Record
JUN
Forrfii
DEP has provided this form for use by local Boards of Health. Ot �her r ' f A �)
" t y L'ged, but the
information must be substantially the same as that provided here. Before using this form, check wi
local Board of Health to determine the farm they use. The System Pumping Record must be subm
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 Worrmaiton
Important:When
,filling out farms 1. System Location:
on the computer,
r �
use only the tab _ �°� "
keyta move your Address W '�
cursor-do not North Andover
use the return —____—,
key. City/Town _. ...
Stare _. Zip Code
2- System Owner:
k �
Name ..Jj
Address(if different from location) .. _...._.. .__.---..__.---.-----...__._..--.—_—._._.—.__
City/Town _.... - ._._.._..__._._..... -—
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping VDa(�' --- _ ' (_..1 �Quantlty Pumped: —
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Ti ht Tank
9 El Grease Try
❑ Other(describe): - - ,_.....__..
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6 . _S.y-stem.Bumped 9y.-,..
__.- --- . ___�__ _
Vehicle Licens-e Numbe-._..._r
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 Facilry
Date -
k5form4.doc•03/06
System Pumping Record-Page