HomeMy WebLinkAboutMiscellaneous - 165 INGALLS STREET 4/30/2018 (10) Commonwealth of Massachusetts --
Citylfown of.No Andover nivel)
System Pumping Record Q3 Z f3
Form 4 rawN
HEAL. HNOR7-H ANDOVER
DEP has provided this form for use by local Boards of Health.Other forms m15
ay be used, but the
information must be substantially the same as that provided here. Before using this form, check with our
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 3101CMR 15.351.
A. Facility Information
Important:When
filling out forms I. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use
y CIthe return
NtCyRcw over Ma
State i Zip Code
2. System Owner.
I
Name i
timer
Address Of different from location)
j Cnyi I own
l State Zip Coda
Telephone Number
B. Pumping Record
1. Date of Pumping
��/ !
pate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 2"Se tic Tank
P ❑ Tight Tank
C3 Grease Trap
C3Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No Ifes,was it cleaned?eaned
❑ Yes ❑ No
5. Condition of System: nn��
6. Sys em Pumped By:
7
Name � n
Stewarts Septic SStVICe Vehicle License Number
Company
7. Location where contents were disposed:
Ste*brrs Pre-treatment Plant 20 So. Mill Bradford Ma 01835
Sna --------
/ Date
Sig a/tura of Recceiving Facil�r
� Date
t5form4.doc•03/06
System Pumping Record•Page 1 of 1