HomeMy WebLinkAboutMiscellaneous - 130 REA STREET 4/30/2018 (2) 130 REA STREET
210/098.=o.0
Commonwealth of Massachusetts
= City/Town of North Andover
07 2014
S stem Pumping Record
y � � � TOWN OF NORTH ANDOVER
<^wM Form 4 HEALTH DEPART',,1 NT
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 Location:
on the computer,
use only the tab 130 (eq, 5
key to move your Address
cursor-do not North Andover Ma 01886
use the return City/Town State Zip Code
key.
2. System Owner:
�UC3�oR�c6�
Name
RlUIl1 .
Address(if different from location)
City/Town State Zip Code
Telephone plumber
B. Pumping Record
r
�f
1. Date of PumpingD e 2. Quantity Pumped: lio s
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. System LBy:
Name Vehicle License Number
Stewart'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
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
TOWN OFA ANDOVER
SEPTIC SYSTEM SERVICING
REPORT
Date.
Homeowner:— -- Pumper A�c-)-Ver
Street Address:
Phone Phone
Nature oP S,=_rvice: Routine .�
Emergency
• I
Observations: Good Condition
Full to Cover j
Baffles in Place
Leach field Runback
-- I
Excessive Solids
Heavy Grease
Roots
Other (Explain)
I
Description of Work:
i
Comments:
• i