HomeMy WebLinkAboutMiscellaneous - 115 SHERWOOD DRIVE 4/30/2018 (60) i Commonwealth of Massachusetts
W City/Town of No. Andover
System Pumping Record
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Form 4
M Syeye
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. Istem Location:
on the computer,
use only the tab - I .. f�Y-Nff
key to move your Address
cursor—do not No. Andover Ma
use the return
key. City/Town State - IVEDEvade
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2. System Owner:
RECEt
IL 0 C\ CC) r) II f
Name
'P"07 TOWN OF NORTH ANDOVER
Address(if different from location) HEALTH DEPARTMENT
City/Town State Zip Code
Telephone Number
B. Pumping Record
7
1. Date of Pumping Date ' f 2. Quantity Pumped: GalIons
3. Type of system: ❑ Cesspool(s) 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 Sy em:
0-1/7 6—"4&q
6. System P ed By: 2
Name Vehicle License Number
Stewa '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 cil Date
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