HomeMy WebLinkAboutMiscellaneous - 115 SHERWOOD DRIVE 4/30/2018 (58) Commonwealth ®f Massachusetts
----- City/Town of North Andover
-- Ss m Pum "ing Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
this form, check with your
information must be substantially the same as that provided here. Before usiRecord must be submitted to
local Board of Health to determine the form they use.The System Pumping date in
the local Board of Health or other approving authority within 14 days from the pumping
accordance with 310 CMR 15.351.
A. Facility informati®n
important:When
1. System Location:
Slling out forms Y
on the computer, 5 SY t
�J
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover Zip Code
use the return State
C"rtyrown
key.
2. System Owner:
a Name
rw
Address(if different from location)
State Zip Code
Cityrown
' Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
Type of system: ❑ Cesspool(s) [ Tight Tank El Grease Trap
Septic Tank ❑ 9
Other(describe):
,u ❑
t
A. Effluent Tee Filter present? ❑ Yes ❑ No -if yes,was it cleaned? E] Yes ❑ No
5. Condition of System:
6. System' BY
Vehicle License Number
tewart'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
System Pumping Record-Page
t5form4.doc•03/06