HomeMy WebLinkAboutMiscellaneous - 143 LACY STREET 4/30/2018 (4) � � 3 ���y sem'
i r,�,���
Commonwealth of Massachusetts
City/Town of DEC 112012
System Pumping Record NORTH AN i �,V�FKR
HEALTH THANDOVER
Form 4 DEPARTMENT
DEP has provided this form fqr 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 1. System Location:
forms on the /ac
computer,use
only the tab key Address
to move your ,.�/�cj✓ AZip Code� c�fil✓s� O'�de
cursor-do not .—.-— _. ._-, ___-- ._. _ .. _ Slate
use the return
City/Town
key. Z System Owner:
Name----- ---- ._..-- - -- --
-
+�^ Address(if different fro0r location)
State Zip Code
City/Town f 7
76
G r✓
Telephone Number
B. Pumping Record
- 2. Quantity Pumped: Dv
1. Date of Pumping Date
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 Pumped By.
Name Vehicle License Number
Company
7. Location where contents were disposed:
---------._-------. ...__ -- ---- -
Signature of Hauler Date
-S--- -----._—_..—_. Date
ignature of Receiving Facility
t5form4.doc•03106 System Pumping Record•Page t of 1
DEP has provided this form for use by local.Boards of Health. Other forma may be used,but the
information must be st#bstantlaily 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 da
accordance with 310 CMR 15.351.
A. Facility 1nforrnation DEC -Fall
Impoltsnt: TOWN OF NORTH ANDOVER
vVnen types out 1- System Location: HEALTH DEPARTMENT
forms on the !_ -1 -
oomputer.use —- - - --
only the.tab key Address C
to move your .�[/° Ae� f
cursor-do not Cgyfrawn - T SCatie� Zip Code
use the return
key 2. System Owner:
Name
Address(if different from Location)
CityfTativn -- - - — State - . . Zip Code - --
Teiepmone Number —
B. Pumping Record
1. Date of Pumping 2• QuantityPumped: -
p 9 Date
Gallohs
3. Type of system: [] Cesspool(s) peptic Tank [❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ,�-, - - - -- - - -
4. Effluent Tee Fitter present? L—T es ❑ No if yes.was it cleaned? (�'T�s❑ No
5. Condition of System:
_ G_�.��t-'fes•----7�-�"� - ... .._ . ..- - - - _ . .. _ .. .- � _.
6. System Pumped By:
Ili G�i� ._-- -•• -• --• --- --- t►ic/ ��--- --•---.--- -- •
Nome ,/---• ,- -- _-------. -. Vele-License Number
Com�sny _
7, Location where contents were disposed:
Signalura of bate —� -
Sigaalwe 4f Receiving Facrliry - Date
15form4.doc•t)31Qti System Pumping Record•P49e 1 or 1
�_L__\ Commonwealth of Massachusetts
City/Town of
- System Pumping Record NORTH ANDOVER
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 P g Qcrnrri m milted to
the local Board of Health or other approving authority within 14 days frornRECOVEge in
accordance with 310 CMR 15.351.
A. Facility information H.
TOWN OF Np�Tt�ANDOVER
Important: HEALTki D'EPARTMI=NT
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your —
_ :_.._ -- --
cursor-do not City/Town State Zip Code
use the return
key. 2 System Owner:
C61 0-'o
Name
Address(if diNerent from location)
CitylTown atZip Code "
�C�)7e
lephone Number
B. Pumping Record 1. Date of Pumping t/29/ 1--- 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? Ed Yes ❑ No
5. Condition of System:
6. System Pumped By:
_ c�I I a�n.� , 6'7
J;m GG �1
Name - _ Vehicle License Number
�l�l�r�cic%V('t --6)V,i_r0fn mfv4Ul—
Company
7. Location where contents were disposed.-
Treatment
isposed:Treatment Plant
Signature of Ha pswie�h, MA 01938 Date
-- - -- --- --- - -----.. - --
.-- -- - -----_...-- —_. .---
Signature of Recceiving F1acility Date
t5form4.doc•03/06 N 15eld J�'�1 t SCS System Pumping Record•Page 1 of 1