HomeMy WebLinkAboutMiscellaneous - 120 LACONIA CIRCLE 4/30/2018 (33) Commonwealth of Massachusetts
W City/Town of No.Andover
System Pumping Record
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 for=m, check with your
local Board of Health to determine the form they use. The System Pu subitted,to
the local Board of Health or other approving authority within 14 days f m t Win
accordance with 310 CMR 15.351.
A. Facility Information -
Important: TOWN OF NORTH ANOOvER
Im
p HEALTH DEPARTMENT
When filling out 1. System Location:
forms on he / �/� �/'� �
comp ter,use �l ) f ( 1 J l r l� f �� f
only the tab key Address
to move your n -_ ___01845
NG.r�i�ucver fVia
cursor-do not
use the return CitylTown State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Z �Lf 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
I
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System P ed By:
-7 2a
Name Vehicle License Number
I
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
ap"ce
Signature of Hauler Dat 11 -22-11
Signature of Receiving Pacility Date
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