HomeMy WebLinkAboutMiscellaneous - 261 CARLTON LANE 4/30/2018 (4)Commonwealth of Massachusetts
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City/Town of No andover
A
System Pumping Record VI
I 'qe�
0 Form 4 -'T
I
U
DEP has provided this form for use by local Boards of Health. Other forms"' , ma lie used, butthe
information must be substantially the same as that provided here. Befoed—usingy'this form, check with your
local Board of Health to determine the form they use. The System Pu'inping 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 CIVIR 15.351.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
&W___h
A. Facility Information
1. System Location:
261 Carlton Lane
Address
No Andover
Cityf'rown
2. System Owner:
('0!5LQ n2n
Name
Address (if different from location)
City/Town
B. Pumping Record
Ma
State
State
Telephone Number
1. Date of Pumping 16- � 9. Quantity Pumped:
[rate
3. Type of system: Cesspool(s) Septic Tank E] Tight Tank
El Other (describe): —
4. Effluent Tee Filter present? Ej Yes 9�No
5. Condition 0
Zip Code
Zip Code
Clallons
El Grease Trap
If yes, was it cleaned? El Yes E] No
6. System P 1905 -By: I--
77�_ -�;S-79 _�
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
11. -
Signature of auler Date
Sign,st6re of Ri6eiving r6bility - Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
'C\ Commonwealth of Massachusetts
112�% City/Town of No. Andover
System Pumping Record
Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
RECEIVED
MAY `1 0 ZU11
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 CIVIR 15.351.
A. Facility Information
1. System Location:
261 Carlton Lane
Address
No. Andover Ma 01845
CityfTown State Zip Code
2. System Owner:
Costanzo
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
4/29/11
Date
State
Telephone Number
2. Quantity Pumped:
3. Type of system: El Cesspool(s) Z Septic Tank Ll Tight Tank
El Other (describe):
4. Effluent Tee Filter present? E] Yes [:] No
5. Condition of System:
Good Condition
Zip Code
1500
Gallons
Ll Grease Trap
If yes, was it cleaned? E] Yes [] No
6. Sys�e�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 Daille I —V-lr
I IN— , tt j �>" ) I (
Signature of ReceiWg F -a -c -Ay- Date'
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1