HomeMy WebLinkAboutMiscellaneous - 165 INGALLS STREET 4/30/2018 (4) _ Commonwealth of Massachusetts
W City/Town of North Andover
System Pumping Record
Form 4
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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. +
I
A. Facility Information
Important: RECEIVED
When .
filling out forms 1. System Location: JUL �4��
on the computer, �� ^ t r 51— 13
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use only the tab (V � � � / _ ___ _ _
key to move your Address TOWN Or NO IM A
cursor-do not North Andover HEALTH 0E('ARTM9ENT
use the return —
key. City/Town State Zip Code
2. System Owner:
_ U
Name — ---- ------------------- ----
mnun
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -b A 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s)
'jeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- ---------- -- ---=- --- -- —
4. Effluent Tee Filter present? ❑ Yes ( o If yes, was it cleaned? ❑ Yes 5,N6.1'
5. Condition of System:
6. System Pumped By:
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
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