HomeMy WebLinkAboutMiscellaneous - 23 WILLOW RIDGE ROAD 4/30/2018 (2)Commonwealth of Massachusetts
W City/Town of No.Andover
CEIVED
w° System Pumping Record iV 20t1
4c,M Form 4 TOWN OF NORTH ANDOVER
HEALT
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
rehun
H DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used–,b—ut theused—,b—u
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
1. System Location:
No.Andover
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
J'f Z4:!� U
Date 2- Quantity Pumped:
❑ Cesspool(s) [,Septic Tank ❑ Tight Tank
1. Date of Pumping
3. Type of system:
❑ Other (describe)
R,d
Ma
State
State
Telephone Number
01845
— Zip Code
Zip Code
vdo 14'
Gallons
❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. SysteR Pumped By
Namd Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart:ptkre-treatment Plant, 20 So. Mill Bradford, Ma 01835
re of Hauler
Signature of Receiving Facility
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
'I"OVY'N N
SYS' -"EN -1 POMPINQ K
UA It RPC
------------
2 13
Rl--CEIVED
OCT 0 7 2005
' I TOWN OF NORTH ANDOVER
Cjj HEALTH DEPARTMENT
SY'STEY .. .... . . .........
Nzo a &
DATA: OF PVMFINQ; D5-.._�-- --.---
'_'
AgOD
yt3
14A rUK4 0jw �Z
! 0,00
U U
ROM 8AY7�.83
OXCUMS SOLID& LEACH?IeLD KUNbAj,
"0LrDCAKAYQyUy,'—" D,C)NEEXPLAIN
'9
t
a rtxu tY
'`' Commonwealth of Massachusetts
�.7 Cityi'f'own of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record mug
be submitted to the local Board of Health or other approving a thoriK,T 1 2 2006 1
A. Facility Information TO.
Important:
When filling out 1. System Location:
forms on the .
computer, use
only the tab key Address
to move your
cursor • do not Cit /Town - — ---
use the return y State Zip Code— -
key. 2. System Owner:
I�C'dnt�a+�
Name
Address (if different from to tion) _._ .... — ......
______.__.-.__--.-
......
City/Town ----------- -State -----
Zi Code
Telephone Number -
B. Pumping Record
1. Date of Pumping �6 O
p g -'�" -- 2. Quantity Pumped:
Date
Gallons
3. Type of system: ❑ Cessp001(s) Septic Tank ❑ Tight Tank
❑ Qther (describe): -
4, Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes Za-�(o
r
5. Condition of System:
vehicle License Number
/W
7. Location where contents were disposed:
SI ature of Hsu — _ - --- - -- ------ - --------.._. _..
Date
http://www.mas�gov/dep/water/ provals/t5forms.htm#inspect
t5formCdoc- 06/03
System Pumping Record • Page t of