The URL can be used to link to this page

Home My WebLink AboutSeptic Pumping Slip - 351 WILLOW STREET 7/13/2015 | � \ � ^ Commonwealth of K8a8sachu ��' of North Andover City/ | {JVV�l v�/ /�[J" , / '^D^^{]\/e[ �� _ ~ ��u��~� nRecord' ��00` Form 4 OEP has provided this form for use by focal Boards of Health. Other forms may be used, tutthe information must be substantially the same es that provided here. Before using this form, check with your local Board of Health ho determine the form they use. The System Pumping Record must be submitted to the |uua! Board of Health or other approving authority within 14 days from the pumping date in accordance with 31OCK8RY5,351. A. Facility information � � |mpomant�When filling out forms 1, System on�eoompv�� ' ]| U ~ 3 �O1� use only � �th e�u key to move your Address `"H``E�1 O[FHD6 P�H F cursor-dpnot N vvm�e��m -- __________________ key. uw'/mwn state Zip Code � 2� System Owner: ' ------- Address(if different from location) ��----- -- -'-------------------------' Cityfrown ��------------------- '' State''----'--'----- Zip Code ' __ � s Te�»x� wom� B. Pumping Record, 1. Date of Pumping 3 .... ... Date 2. Quantity Pumped: Gallons [l Other(describe)* -- ------- ----------------------'------ — 4. Effluent Tee Filter present? Yes I] No |f yes, was ` cleaned? Fj Yes El No 5. Condition nfSystem: , | --'-------------- O. System Pumped By: Na Vehicle License Number art's Septic Service 7. Location where contents were disposed: 6tevvart'm Pre-treatment Plant,-20 So. Mill-Brad!9rd,-Ma...01-835 Signature ofHauler �------------- --------'''-'' - --------------------- oovy S�natv"eufncoexx�pa v-' - -- -- - ' --- Date --------- - - '----------'---- mmnn4.umr03m8 System Pumping Record'Page Iof1 � Commonwealth of Ma sachusetts City/Town of North 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 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 RM, �'NED filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor-do not North Andover 'TOWN OF ,dM I I use the return 1-1EA I key. City/Town State ObdeiJ r F� WQ 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Recordo,, ------- 1, Date of Pumping Date -Qdb) Quantity Pumped: Gallons 3. Type of system: F1 Cesspool(s) WSeptic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): ------ 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? El Yes ❑ No 5. Condition of System: 6. System Pumped By: me Vehicle License Number S�tewart's �ervice om ompanyyy� 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 -d6--nabu—re of Hauler ------- Date ---------- '�igna—tureo—fRe—ce-iv—in-g--,F-ac—ili-t,y--' ',- Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Ma8>sachusetts City/Town of North 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 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: „„IV E 1) on the computer, use only the tab —�. . _ _� /..-.--"'__ .__._.'_ t key to move your Address cursor-do not North Andover use the return key, City/Town State 1411p"C000 2. System owner: __-_- _ _ _.'fie__..,�J_ . ._ _. . . -____ _.______ Address(if different from location) City/Town State Zip�4de Telephone'Nu"m—be,r-- B. Pumping Record 1. Date of Pumping a Quantity Pumped: - te 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 i-t cleaned? ❑ Yes F-1 No 5. Condition of System: 6.�ei,m e Vehicle License Number Stewaq 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 Ma8sachusetts City/• own of North 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 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 R�E E filling out forms I. System Location: C E D on the computer, use only the tab ❑❑f_v .`. �.. _.__ .i_!!_._._. ___.__.__ 4 3, key to move your Address cursor-do not North Andover use the return ........... ... key, CI /Town State Code 2. System Owner: Name rerun ---------—----- Address(if different from location) City/Town State _Zzp Code-- Telephone Number___' B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: Cesspool(s) 5 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. System Pumped By: Name er Vehicle License Number Stewaq°�Se tic Serylc�_ 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 I of 1 Commonwealth of Ma8>sachusetts City/Town of North 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 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 CIVIR 15.351, A. Facility Information R ED Important:When filling out forms 1. System Location: on the computer, 3 T15 use only the tab key to move your Address 'V0Vfl4 C)F�"K)Hfld�M"'DOV['-TZ cursor-do not use the return North Andover key. CityTFown State Zip Code 2, System Owner: r ........ Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped. Ga o n 3. Type of system: ❑ Cesspool(s) [91Septic 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. System Pumped By: 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-03106 System Pumping Record •Page 1 of 1 Commonwealth of Massachusetts City/Town o o n over o 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 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 M(�$' I use the return North Andover key. City/Town State ip'Go 2. System Owner,-,. Name return Address(if different from location) City[Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Quantity Pumped: Gallons ale 3. Type of system: ❑ Cesspool(s) WSeptic Tank ❑ Tight Tank ❑ Grease Trap Other(describe)- ------- 4. Effluent Tee Filter present? ❑ Yes [:1 No If yes, was it cleaned? ❑ Yes E:1 No 5. Condition of System: 6. System Pumped By: 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__ f ---* ---"-- -- Receiving -D"a-t-e- t5form4.doc-03106 System Pumping Record•Page 1 of 1