HomeMy WebLinkAboutMiscellaneous - 1049 TURNPIKE STREET 4/30/2018 (3)r
�, Commonwealth of Massachusetts
n�ol City/Town of
MR
System Pumping Record NORTH ANDOVER
Form 4 r forms may be used. but the
DEP has provided this form for use by local Boards of Health. Otho
information must be substantially the same as that provided here. Wore using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record
must be submAted to
the local Board of Health or other approving authority wittiln.114 days from the pumping date In
accordance with 310 CMR 15.351
A. Facility information
Importarit
Veen f1l" OW System Location:
orms on fter, use 1 154-
f 1.
con"t0-el-P T.
ordy the tOb kuy Address eAZip 0,949r_- -
to move your COd6
cursor -donot dkiftown
use the return
key. 2. System owner:
lore, Z3.4 I
Nam
Address R
iii different (win Wi;f -W)'
§6te zip Code
T.4t�-- NLqnber
B. Pumping Record_11a&20
17- eq .-/ Z�___ 2. Quantity Pumped: Gallons
1. Dale of Pumping Date
3. Type of system: [5,1fe-�Sspool(s) septic Tank [3 Tight Tank Grease Trap
Other (describe):
4. Effluent Tee Filter Present? yes 11 NO if yes, was it cleaned? C3 Yes 0 140
5. Condition of System:
4'� JE_ - - __ ___ . . - - . .. - -
system Pumped By. t-11--7-
Name
Company
7. Location where contents were disposed:
o1 liaulerr.
#0?thW0VlM MA.
Vale
,I
System pump -Ing ftecord - POP I Of I
lWarrm-daeom
use by jocal Boards of Health. other,forms may be used, but the
`, DEP has provided ,this form for l the same as that provided here. Before using this fort; check with your
information must be substarttlatly,
local Soard of Health to determine the use. The
W th1n 14 days frostem mn he pumping date in
�tted to
the local: Board of Health or other approving
accordance with 310 CMR 1 5.351
A. Facility Information
Important:
When fiifing ail
forms onthe
computer, use
only the t9b *
to move your
cursor - do not
use the return
key.
1. System Location:
T 04
Address
lly/rown
2. System Owner:
G I >✓ /
f�18m6
Zip Code
I dress ;if different fromlacaGan)
-- ----- . _.... .. -" -- Sista —.. -- -- Zip t;,ode •- ...... .
Telephone: Number -
�. Pumping Record
% 1 � ' 2. Quantity Pumped: �
1. Date of Pumping Pete'
3 Type of -system:esspool(s) ❑ Septic Tank [] Tight Tarek [j Grease Tfap
[� Other (describe)' - -
4. ,Effluent Wee Filter present? C] Yes C] No
5. Condition of System:
6. System, Pumped By
Name
_t�1
Company
7. Location where contents were.disp..oW:
If yes, was it cleaned:? D Yes Q; No
Veh=icle License Number
--
__.Neft A o MA4 -_ - — - -
Slgnatur� of Hauler. a .
Signature of ReG$iVing i=aGlily _ _ ... _—• ._.. -- ate ..-----•-- --`
System Pumping fteeord • Page 1.01 #
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