HomeMy WebLinkAboutMiscellaneous - 165 INGALLS STREET 4/30/2018 (11) C'EMW
Commonwealth of Massachusetts
W City/Town of No. Andover JUL g ��t
a System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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SVO
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 1. System Location:
forms on the
computer, use (c57 nwrff)
only the tab key Address
to move your No.Andover Ma 01845
cursor-do not
use the return City/Town State Zip Code
key. 2 System Owner:
tab
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Datteo Gallons 2. Quantity Pumped: —
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. S stem Pumped By:
oo d
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 Haule Date
Signature of Recei ng acility Date
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