HomeMy WebLinkAboutMiscellaneous - 166 GRANVILLE LANE 4/30/2018 (2) j 166 GRANVILLE LANE e
// 210/1.06.C-0075-0000.0
Commonwealth of Massachusetts
City/Town of North Andover
SYStem Pumping Record
Form 4
wy al Boards of Health. Other forms may be used, but the
DEP has provided this form for use by loc
information must be substantially the same as that provided here. Beforeusing
this
Record must ch ckwitsubmitted your
he form the use. The System Pumping
t Y
to
local Board of Health to determinee in
the local Board of Health or other approving authority within 14 days from the pumping a
accordance with 310 CMR 15.351.
A. Facility information
Important:When
filling out forms 1. System Location: T `
on the computer,
use only the tab
key to move your Address Ma 01886
cursor-do not North Andover State Zip Code
use the return City/Town
key.
2. System Owner: c)
a Name
Address(if different from location)
State Zip Code
City/Town
Telephone Number
B. Pumping Record
�/ • '� Pumped: /-
1. Date of Pumping Date 2. QuantityGallons
3. Type of system: ❑ Cesspool(s)
Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? EI Yes ❑ .No if.yes, was it cleaned? E] yes ❑ No
5. Condition of System:
6, System Pumped y: l�`�
vehicle License Number
Name"
Stewarts Septic Service
Company
7. Location where contents were disposed:
Stew 's Pre-treatment Plant, 20 S Bradford, Ma 01835_
�r4 d
Date
Signature f Hauler
n
Sig atur eiving F ci i
Date
System Pumping Record•Page 1 o
t5form4.doc•03106
I
i
Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping rd ul�L 0 8 2014
ys p ng Reco .
Form 4 TOWN OF NORTH ANDuvER q
HEALTH DEPARTUE
DEP has provided this fond 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.
. A. Facility Information
1. System Location: Left/Right front of house, Left/ i ht rear of hous Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
/ 67
/` 7 6L _ 9^ -
c4frown State Trp Code
2. System Owner.
Name*
Address(if different from location)
City/Town � .. State� ^ -� `Zip Code
Telephone Number
f:.
B. Pumping Record
1. Date of Pumpinggate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) is Tank El Tight Tank
❑ Other(describe):,
4. Effluent Tee Filter present? ❑ Yes ❑_K0 If yes, was it cleaned? ❑ Yes ❑ No:
' 5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises rises IncCompany
7. a contents were disposed:
G.I S. Lowell Waste Water
I c
SignIfitufe qf Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
�LN Commonwealth of Massachusetts
City/Town of North andover
System Pumping Record
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 usingthis 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 Location:
on the computer, 1 „ C
� �� one-
key
e—
use only the tab �J �ty
key to move your Address
cursor-do not N. Andover Ma
use the return City/Town State Zip Code
key.
t�
2. System Owner:
Name
reom
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 1 2. Quantity Pumped: �ailo /0-4, C)
3. Type of system: ❑ Cesspool(s) O Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes q No If yes,was it cleaned? ❑ Yes ❑ No
+ 5. Condition of System:
1
6. System Pumped By:
Name Vehicle License Number
i Stewart's Septic Service�
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Si Date
nature of ci Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
�.�
Form 4 JUN 15 2009
DEP has provided this form for use by local Boards of Health. Othe fV"b7mm[lyra
information must be substantially the same as that provided here. B ford 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.
A. Facility Information
Important:
When filling out 1. System Location: Left front, left rear, left side of house. Right fro , right rear right s' oho .
forms on the
computer,use A
only the tab key Address `7
to move your.
cursor-do not
use the return Cityrrown state,__ Zip Code
key. 2 System Owner:
Name
Address(if different from location)
Citylrown State Zip Code
- �= �c
Telephone Number
B. Pumping RecordLip
1. Date of Pumping Date Quantity Pumped: Gallons
3. Type of system: Cesspool(s) eptic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? Q Yes o If yes,was it cleaned? Yes No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
.S.D Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
I t°rt� lj�yy
rcyfyyr4`d j.j> Tt1 fF'7Vf1 !I � �
' ,FAe ffik'I`f�`�'�4���>,;�•��hf °L�Zf` r���p.d'1�7rg4�,.7e,5ltt . I
- we �lassacuse qL
DOVER MA ACRS
P".,-r �Yo�rn of; of N
OR AN
t1ping.Record., HEALTH EPARTM LAVER
Form 4 r
DEP has provided this fort for use by local Boards of Health. The System Pumpg Record must
be submitted to the local Board of Health or other approving authority.
X Facility Information
Important: y
when UN out 1. S st m Location: "
forms on the
I�Wb key Add
to mow your
" cursor•do not gtYlT State Zip Code
use the retum .
tceY..•, 2. System Owner
Name
Address(If different from location)
CItyRONm State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping a
Quantity Pumped: Gallons
3. Type of syst®m: ❑ cesspool(s) Keptic Tank ❑ Tight Tank
,` ❑ Other(describe):
4. Effluent Teo Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
S, Condition of System: .
U:-4
8, Pum 6y:
vehicle
Uoense Number
Y.
7. Location 1wtpre contents were disposed: M z
14�
r Date —
httpJ/www.mass.govldeptw'aterlapprovalsttSforms.htm#Inspect
t5forin4.d00,08103 System Pumping Record-Page 1 of 1
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RECEIVED
DEC 0 05
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTP-?\'1 PUMPINU R 2COKt..
. ��� SYSTEM 1..;',�•,� I'?�,,�• .,..._... .... � ....... .._..
. _Q0,071TY
h., rVX6 ON seRYI �
� ., bhlt�Kllt:Nt,
Ub�ttRY.1'fiUNJ. ... .�
000D CON01'>'IUN rVLL ru wax
RZAYY OXBh38 L 85 IN f'l
SOL
CA
KAYQY�� Out
.. . ,_.., ER PI.AIN
0.
.
f• �� p �
uhI•M►'� tx�irr�rr�xr v n
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE I V O V ! aO63
SYSTEM OWNER&ADDRESS SYSTEM LOCATION --~
l�� r�nU�lle Larc-e. �G-l�
/U .QNdoyer
DATE OF PUMPING 11-7 QUANTITY PUMPED zl SQ�
CESSPOOL NO YES SEPTIC TANK NO YES ✓�
NATURE OF SERVICE: ROUTINE L----EMERGENCY
OBSERVATIONS: /
GOOD CONDITION FULL TO COVER
ROOTS GREASE BAFFLES
EACHFIE D RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY 4i,oj 691/G,l-
COMMENTS:
CONTENTS TRANSFERRED TO
SYSTEM PU,,mPINC FZEC0 '?_��� -�
D-C -- 5 202
U ,I�IR DR - --
CSS SYSTEM
r-;"l,-11t111111,9 11,-ZlW—:" i3ayk, I
N0 lam/ YES
S �RVICE R0U"i INE — E�1LRCf:
i� 0C) D UNL)I i 10N l L! ?
RUCTS L E CHFI` ! J
Jr-
---
�XCESSIYE SOLIDS FLOODED
—„
SOLIDS CARRYOVER O H F P (EXE! -a. ---�
; � T! FCRIZL0 I'U
i
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: `
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: QUANTITY PUMPED_Z, bD GALLONS
CESSPOOL: NO _ZYES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE C_/ EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: AYIoam— Se -�j C,
COMMENTS: L°C„
. 1
,CONTENTS TRANSFERRED TO: S) 1 t S+'
/address 9kAwVci�,L AcU Title of File Page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Reber to other Purpose of Document/Action and notes.
action Document/ document/
Num. Action Department
Board of Appeals - Board of Health - Planning Board-- -
Conservation Commission - Building Department
i
T0: _ c
120 Main Street
N ANdover, MA
. 1
10
_ LOUIS MAGLIO
166 GRANVILLE LANE N ANDOVER, MA-
i
000392358 633 2
Less Of 3/6/84
F= 1E o� Cla J. G891346
C`V Vehicle damage
LT'.:C A1C:. G. i.r:c c: -'vc
C.. T.E E:�I:E; EYCEE� �C_}C . U: C:" Ca. sE 7:�'c GEr ie'r•'� �
Cc.'t O:IE e
C;,=r':ET' LC. GE a _Ca�'iE . 1` a .: T:C :CE L! :)E 1icS5 liE7,
li.-} � -- rr i - E C-E=Et C_. C7 -Z .
K. � .E:•�c'. E_:.__ c .^ECE."E: `c L';E C_-�_ =.:C ;:._1"E �G:c
Cc:,E Cr 1CCC C1c_ :. C':"
C'a'.:sez COr_EE Oi C
aL tf,E tr1E aGCT'ESSE: 1T1C1CaLECab0�'E }" f1T'a: class Ma11
`
DA11j1"F.1,� OFFICE Of TEiF T%AVEI-EF INSURANCE COK3Ah-ILS-
Federal Svc:. DemerE. Massa churl^.t� 0:52: 7elephonc. (6), 7--2FX
F
CQMMONh�`�.
PR0I�a$E� o aA
z m o b
JS OVC
_A__/SPp-sus 6�
2 ti
. .. - ........n.v�.C^+f.q�+�v.wy.�'rvm:.�.1`�.T.•fw�W..,MAn's'+�iT^^'A..y'.v.�+.K+y� w.�wM+n�wP.xa��
............. .. ..........
"OWN OF N TH ANDOVEP,
SYSTEM PU PIN(} RCOIZT)
SYSTEM OWNER.dt ADDRESS SYSTEM LOCATION
u - �c
DATE OF PVMPiNQ:_`f 1�"_Q
QUANTITY PUMPED: T
1 01POUL: NO-.... . _...... Stlptic Tank: NO \
NA WRE OF SERVICE: Kou'fINE EMERUlrNC'1'
OBSERVATIONS: DEC 0 7 2004
000D CONDITION FULL. 'I'U COVER
HSAVY OREASE BAFFLES IN PLAC L TOV +v C=NORTH ANDO�,'=R �
ROOTS LWHMELD RUNBACK F,C.%LL H DC-PAR_. EN
OXCUSIVE SOLIDS..___ FLOODED
SOLID CARRYOVER._..... ..OTKER EXPLAIN
Jy.�em Puntpcd by
C:po.__.c�.,. rr1��... .
t'UMMENTS.
CUN I EN I'S fKAN8k-bp RSD ro
IOU
(�rU�ddle
���-�
c -
6,Ua�`%��r� .
�O�e GcJGrG D� �D�
� -� ��,�
l
TO: NORTH ANDOVER, MASS /� 19 7C
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
LQ7 31 241y,/� North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19 G�g�TTS N
J !)
eg. liginmer/Re ..,S'Anitarian
d�
?L6AI
__��✓ '�.T l�vr�/�A____�_� --= GAA,u a—C_�.,00ysr- Cc .
�V/�/a• �l=/�.�_r`'�+f_.C-�--.-/_j1 rS�SS- - ��--�'�Y,�t� E__sr'.... _
}
P�t�t OF
dt oma' JOSEPH `Gf
V J.
A` A No. 404
vat
4
- f
i
I
TO: NORTH ANDOVER, MASS 'D '�5 C ' 19 7 C
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
Z Q 7- c3 l C R/l N V C`l,-- North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
-NIA,
N, O r
a�
J
(w P fq: aY.gi4n�eer/Reg. anitarian
f
C,'
IMM OF NCRTH ANDOVER. NORTH ANDOVER BOARD OF HEALTH
REPORT OF PERC TEST
_ ADERESS OF SYSTE21 i //ee /..ak�.t.�G iPJ -7/ _ DATE
NAME OF PROFESSIONAL ENGINEER. Cit SANITARIAN CONDUCTING TESTS
-�
NAME OF LOT
MINER Cj Cc.r/'-" ADDRESS
SHOW APPROXIMATE LOCATION OF PITS ON SKETCH ON REAR. OF THIS SHEET
Total
Soil Log: Topsoil Subsoil _ ` D the & s Water Level Pit D th
/
Time to Time to
Pere Tees -s/y- Depth Saturation Time Drop 12" - 9" Drop 9" / 6"
Iy / fC
-Cep do
?11a 7` �07 7
Other Considerations:
.Irl��J/ra..
Recommendations:
f
ALI—
Signature___
AL..,
xo�-1
S •
/�) o o �i�
.1'oa-� -4-•'40 �,,
a 29
P.C'OPO.S ED SU6 SUR FAGS
SEWA4,4=-
pos& Sys rew
A�vo
PRo o odeo ZO'T aR,4tb/i4-/G
/ DATE
OWNE,2 : sT co.
LDCAT/aN.:
-per �oG _ ' �✓' �'`��S' cTosEP,v �T BAR OA�aALL
` I WEsrwARD
Alo. REA4VA45, , MASS.
9 � __ r � � � S,�• �2 �JE.r \ ..y Ota ••,,
DES/G AJ D A TA
TYPE OF QU/G D/R/G= 4 f3�"%JJPooitt 1ftNEL L/.�/U
� � CARAG E � CELL,4� PLUMB/NU FAC/G/T/ES� �✓o�'./c
FLOW EST/MATE: G.,a ck
o 7-AM K SEPT/G TA�vk
— 10 � A6so2P r/o�v ,4 REA : ,ADD s:K"' .�SD��r�o�✓ .B�Z�
1 107-E- B� - ate•. �' _ a�
- _ - ZPERGOLAT/oAj TESTS
v 4
,B✓TTOti1 E4EVAT/ON 07,67
f
IVg Y .8E /A4Sr,4 L L ED 19z- \ � �F sAT-11RA T/oil/ /5 �f�l/ M/N. ,t.1/N M/ti✓.
114 7-/E GrQOJ�C�-yE-L� l /Z"To 9" DROP /7 10/A./. Ml". M/N.
8Z 9•• To 6" ORoP Z9 i(/j/ iU///�/ M/N. NI/N.
qC ,� Pe,PColAT/ON RArE /o M�N.�/v. �r�1.N//N, /NDN //V �I�N At.
TEST PITS / r�Z34
DA rE
\ \�\ TOP E4EVAT16AJ JI/,p
\. s ?e 2a'-?zif'Saic
�j011w,''
s�
/D4 SZ' - 9. AND
'74i \ WATE,2 TABLE
_ �C�3 COCA 7-/40 N Ato Wgi T2
l I BOTTOM EGEVArioN n
$E7JC K TE57T W/Tit/ESSED BY itl0. ANDOI/EQ . HEAL7iq L7EPT.
EL. ?9. �� �` ��S a� ��6 P,1-4 Al oF` 2
ell
y
`F EIaGEZ) . 701AlT", soLin P(�C. PIPE
_ . Coe EG?[//IIA LENT)
m e. e er o-p, e 6 s n o o e e'�c .. o e .e• a e O c
� o e d' CAPPED �i(!DS
U C7
[ 2_�„ s_D," � o S-p" _ � 2'-�" C7�-� �.,`PE.2FoeATEL� �•.�. P/Pc
EQalVALENr)
h
p4/eT/AL BELS EA./D SECTIOA-1
SCAZ-E /2 =� -D - AeEA = 90015-
h N
(Fo,e SPEC/F/CAT-/oA/S - SEE sECT/DAJ SIT GOWFe .2/CayT)
h��T2IBUT/Dw �X
/DDO 67.4L. COA/COETE 5EP7-/C r4A1lC 4,5
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1 �J
18.50AP7-/QAJ BE0 /PL A N
9� A,107 TO cS'CAC E
4"1�4
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//7
_Ex,s, . estpE_ sP v c s • . _•• - • . . I N ?
peopP/PE
/ 0,. To j/B bfl, SHE�
r Oovn♦ . C a A.e o tJ moo • * ee e'�a•oe C�U.S/fFa STO�/E a • e o e 2
0
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s
JY 14
ND(- AN1Ywer
STEn1ART S SEPTIC TANK SERVICE
)Zd A O,n St 47 RAILROAD STREET
A/A/lh A nmwae- BRADFORD, MA 01835
14-mal Lie- ISI-pp Fl 978-372-7471
LnJc+all
MONTHcp Ucf-aber- c�)�O
MMUW REPORT
FOR TOWN OF _/Vo A n rdye�
----•��
DATE
ADERESSGALIDNSCMENTS
l4 d 5�9 ✓em S Mod
f0-3_ . Ia5 &)Ck-y Brboe ma IJ56o
,per -------
1600
16 76 Tuc r1n p {
1a 1466 vin r 5t I
l 6-6 79,o /e
10 --1U /i ,7 �� � �-.
1 006
5 o nd fit.
56 6
/10
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. ` +••��, V n'l.,y, ,1. :.'.., .... _ � ..'! ' r•, ..
ORT�i-ANDOVER MASSACHU I
MOMump ,,.1,
r S � tI� ,1n.O"Record'
m NOV C' 6'.2007
•r•%' S,t �C'•.i
.{• .,•l,;:r y `� ! •.n{k%�r,�r�l;�("iv,":n:•<;', 't �,..;;'�rl;rta.•t ;r:'�,�
';t1.f,���tJr',:.ji T�qd 1,,,4,,.:I r'.i w,.,:'.;:.,,.{,,.uliN„ ,;r.l. �'.r•. ,'� �.
DEP,.has rovlded W�`''' F'• `
p, thls form for use by local Boards T!
l� �, l
m �Rec 'rd S 'TTS
�,.I,. o
. �., 1,'��i_.. �./�'i: �+Q"•'mJI �r.`i�.r!��'w. �;�)����•��•,1;'Y�l�y�'/1 C,A��.i 1.. � � � � � .. ,
•.,, ,•;... ..yl'..�; NOV 1 3 2008
DEP.hai provldod 1h(4 lora for t eo y !p,al boar a or
Uo e' brnl;{od (o the IOCaI 6oarc C'r nol
' a (n or c(no
HEALTFY'
6E'r
A, FaC 11l y Inforn)atlon
^�. r Sy�s:Qm LouUon;
"•) :^.e lt,^nor .^r61 J (� KY
Owner
r �drei� tit Qvforenl ---------------
Tolopnono rv;moof
F I-PumP Ing Rekord
_
�•,\ .:,III j.. .. , -. :� . ',>,:I,:a'I' ��.`
l
Y C999p001(9) gPUC Tom, rl
• �� (describe): .
4; Etfluanl Tea FII(a�, r�;en(? r' Yo9
r`Io
9. wag I; C!6an8Q? Yes
on
i ;� r'r "�(r Yt! '1� yn 1�rJr.ij �, ,:'• J VB11(d9
�.1C9 n r
.,'.
. r,��•��,,�I�..�i4� .;�'ji��fn'����A (�.{�,rY.:w��/dl������lll�/ti(�j,�',��l,l�: � /
' I� ..J'•1,�� LOCA ' '.
on where co�(enls'ware di9posed:
• " ;;. � iii ` :.i, :\;'.r,'I
".-,.,,�„�w.mass.8ov/dBpNreler/approve/Is/fblorms.r�mnln9oocl ._.
Commonwealth of Massachusetts
upCity/Town of NORTH ANDOVER MASSA H
System Pumping Record . � ��
Form 4
DEP has provided this form for use by local Boards of Health. T eT i i lgWW must
be submitted to the local Board of Health or other approving aut A H DEP RT ENT
A. Facility Information
Important:
When filling out 1. System Location:
forms on the // / C-7 t O n II I/l/'�
computer,use J (Q(� �-- 1 'C_
only the tab key Ta�
esss A0,
r ]to move yourcurA0 1�S6 .
use the
returndo City[Town State Zi Code
use the return P
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping i 2. Quantity Pumped: �LitJ
Date Gallons
3. :Type of system: ❑ Cesspool(s) ffSeptic Tank ❑ Tight Tank
-] Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
�e
6. System Pumped By:
Mae- < n u)
e t Vehicle License Number
Company
7. Location where contents were disposed: 74
Signature of Ha ler Date
http:/Avww.mass.gov/deptwater/approvals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
W 013
City/Town of North Andover013
'
System Pumping Record
Form 4 "- -T r
�M
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 Location: �
on the computer, /
use only the tab � o ` V
key to move your Address
cursor-do not North Andover Ma 01845
use the return
key. City/Town State Zip Code
&� 2. System Owner:
Name
velum
Address(if different from location)
Cit /Town State Zi Code
Y P
Telephone Number
B. Pumping Record
1. Date of dumping 2. Quantity Pumped: K)DO
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
El Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: f
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
St rt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
ignature of uler
Date
/
Signature ler
Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1