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Commonwealth of Massachusetts
W City/Town of No Andover
System Pumping Record
iG^M
Form 4
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� OC tl0�t:
on the computer, /
use only the tab
key to move your Address
cursor-do not No Andover MA
use the return
key. City/Town State Zip Code
2. System Owner
tab ,// �/�...•G�I
Name CJ
rnnen
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record-- -----------:_�— —
1. Date of PumpingDate' 2. Quantity Pumped: Gallon
3. Type of system: ❑ Cesspool(s) IN/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 Pumped Bim,
Name Vehicle License Number
Stewart's Septic Service F
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 _
Signature of uler Date
Signa re of Re Facility Date y
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Commmonweal-h of Massachusetts
RECEIVED .
CitylTown of North Andover MAY 1 1 2015
fid TOWN OF NORTH ANDOVER
System Pumping Reco
.� HU,LT1-1 DEPARTMENT
®r
w` 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 musL.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. Faci9ity information
important when
filing out forms 1. System Location:
on the computer,
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover Zip Code
use the returnCState
City/Town
key.
2. System Owner:
Name
rmpn Address(f di�erent from location)
State Zip Code
Cityaown
" Telephone Number
B. Pumping Record �
1. Date of Pumping ate uantity Pumped: Gallons
Tight Tank ❑ Crease Trap
3. Type of system: E] Ti Cesspool(s) Septic Tank ❑ g
❑ Other(describe):
No If.yes,was it cleaned? ❑ Yes ❑ No
4. Effluent Tee Filter present. ❑ Yes ❑
5. Condition of System:
6. Syste um d By:
Vehicle License Number
Nam
L'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
t5torm4.docc 03/06