HomeMy WebLinkAbout- - 1048 GREAT POND ROAD INIVP
Commonwealth of Massachusetts mm
X
City/Town of North Andover
System Pumping Record
------------------- 0 Form 4
DEP has provided this ,,"orm 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 Add
cursor-do not 7-3, MA
usethe return .......—-------------- ------------------------.................... ............ .............
key, City/Town State Zip Code
2. System Owner:
VQ
Name
—--------------------------
Address(if different from location)
..........
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping9�IVIZ2- 2. Quantity Pumped:
allon
Date ' (�- s
3. Compon nt: El Cess7S
ol( ) F-1 Septic Tank F Tight Tank R Grease Trap
('! 'P
p
q7thner(describe): 601 r,
4. Effluent Tee Filterpresent? El Yes Q,-No If yes, was it cleaned? E] Yes Ej Na
5. Observed condition of component pumped:
6. Sy em Pumped By:
A A
Name Vehicle License Number
Stewar
ZS�tic' 58 So, Kimball St., Bradford,MA
Company
7. Location where contents were disposed:
,,,-"20 So. ill St., Bradford, MA
Signa ure of Hauler Date*J'l
.............
Signature of Receiving Facility(or attach facility receipt) Date
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