HomeMy WebLinkAboutMiscellaneous - 116 BRADFORD STREET 4/30/2018 - �P���vt;� .5'i --
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Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authorit�j..'—
RECEIVED
A. Facility Information MAR 0 3 2006
Important:
When filling out 1. System Location: TOWN OF NORTH ANDOVER
computer, use
forms on the HEALTH DEPARTMENT
'
only the tab key Address
to move yourd �1-&��
cursor-do not
use the return City/Town Sta a Zip Code
key.
2. System Owner:
Name i
Address(if different from location)
City/Town State Zip Code
g -� -��6
Telephone Number
B. Pumping Record
Date of Pumping Dat 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye sNo If yes, was it cleaned? ❑ Yes ❑ No
5. Co ition o€�System: �---
� 6. Syste�Pum
( _ Vehicle License Number
Company
7. Lo ti where contents ere disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm*inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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RECEIVED
TOWN OF NORTH ANDQVl r. JUL - 6 2005
vart �o`
IBoC SYSTEM PUMPINQ CORj:j
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
3 `STE O"BR ADDRESS
SYSTEM LOCA71ON
l� m i
`LWOOL:
NA t"d, K4 OF SBRvieE:
W$UA V A,nom;
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13A.P3'1.BS IN FLACL.
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JAN - 6 2003 9
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r± F'AVY CREASE 13AFFL !I'S !� ----
ROOTS LEACHFI "! -- --
CXCESSIVE SOLIDS FLOODED ---
SOLIDS CARRYOVER -- OCHER ,EX
_ 1 J 1'!tANSFCIMED TO
RECEIVED
Commonwealth of Massachusetts II
w
City/Town of North Andover MAR 0 7 2013
System Pumping Record TOWN,OF NORTH ANDOVER
y HEALTH DEPARTMENT
Form 4 -
M
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 Loc tion:
on the computer, — //G (�
use only the tab
key to move your Address
cursor-do not North Andover Ma
use the return Cit /Town
key. y State Zip Code
raa
2. System Owner:
A AI Name
iemm
Address(if different from location)
CitylTown State Zip Code
i
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
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 it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. tem Pum ed B
C
ame Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
St d Ma 01835
I
Signature of er Date
Signatur f Rece ng Faci ity Date /
t5form4.doc•03/06 System Pumping Record•Page 1 of 1