HomeMy WebLinkAboutMiscellaneous - 266 GRANVILLE LANE 4/30/2018 (2)N)
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Commonwealth of Massachusetts RECEIVED
CityfTown of North Andover MAY 112015
System Pumping Record
Form . 4 TOWN OF NORTH ANDOVER
qEALTH DEp'%TeMENT -
DEP has provided this form for use by local Boards of Health. Other orms may used, but the
formation must be substantially the same as that provided here. Before using this form,. check with your
in Pumping Record rrlus-L-b�e submittedi.0
local Board of Health to determine the form they use. The System
roving authority within 14 days from the pumping date in
the local Board of Health or other app
accordance with 310 CM R 15.35 1.
A. Facility Information
1. System Locationi
Address
North Andover
C�,y/Town
2. System Owner -
Name
Address (if different from location)
City/T ovVn
Glynad%`
Ma 01886
State Zip Code
State
Telephone Number
Zip Code
B. Pumping Re cord /�6a)
A-V �fkt 6/Y2. Quantity Pumped: -E-allons
I . Date of Pumping Date
3. Type of system: Cesspool(S) vseptic Tank Tight Tank Grease Trap
Other (describe):
4. Effluent Tee Filter present? F Yes F No -if yes, was it cleaned? [] Yes [] No
5. Condition of System'.
6. System P m ed By,
—Ve—h-,—cle L�iceseNumbe,
,--�S�Name
StSt �� Septic S
— L s
tompany
7. Location where contents were disposed:
Stewart' s Pre-treatment Plant, 20 So. Mill Bradford, Ma.01 835
Signature of Hauler Date
Signature of Re:eiving Facility Date
System Pump ing Record - Page
,5',orm4.doc- 03106
Important When
filing outt torms
on the computer,
use only the tab
keyto move your
cursor - do not
use the return
key -
Commonwealth of Massachusetts RECEIVED
ClLyffown of North Andover
Mg 112015
I M rumpin$j
��ys .. TOWN OF NORTH ANDOVER
Form 4 jjEAL7H I)EpARTMENT
A �\"i �hp
DEP has provided this form for use by local Boards of Health. Other rms may be use , I
in-tormation 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 mu�t'be * submi"LLed to
Lh within 14 days from 'the pumpinq� �ate in
the local Board of Health or other approving aut ority
accordance with 310 CM R 15.351.
A. Facility Information
1. System Locationi
Address
North Andover
City/T vn
2. System OwnArL',,
Name
Ma 01886
Zio Code
State
Address (if different rom location)
Cityf -I yv.n State
Telephone Number
B. Pumping R,ecord
2. Quantity Pumped�
1. Da�te of Pumping Date
3. Type of system Cesspooi(s) Septic TanK LJ I Ig"L cl"
F� Other (describe)�
4. Efiquent Tee Filter present? F� Yes [] No
5. Condition of System-.
6. Syste e yl
Name
tewart's Septic Service
Company
Zip Code
4T�_f) -
Gallons
[] Grease Trap
.1f.yes, -was it cleaned? [I Yes [] No
7. Location where contents were disposed'.
Stewart's Pre-treatment Plant, 20 So. Mill Brad :)rd, Ma 01835
Signatu -e of Hailer Date
signature of Receiving Facility Date
t5form4,doc- 03/06
Sys'Lem Pump ing Record - Page
L 49's
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
7
DEP has provided this form for use by local Boards of HeaFlth. The S�stem Pumping Record must
be submitted to the local Board of Health or other approvihg authority. I
I NOV 0 9 qnn7
A. Facility Information
System Location:
90 62AW-q1U4-- LAN
TOWN OF
Address
Nozx-h
City/Town State Zip Code
2. System Owner:
Vi [,�, ?ARAb I SE
Name
A
Address (if different from location)
City/Town
B. Pumping Record
I
1. Date of Pumping
3. Type of system: El
El Other (describe):
State
Telephone Number
- -7 & �? LO -7 2. Quantity Pumped..
Date
Zip Code
Gallons
Cesspool(s) �X Septic Tank El Tight Tank
4. Effluent Tee Filter present? $ Yes Ej No
5. Condition of System:
6. System Pumped By:
If yes, was it cleaned? % Yes E] No
7:S06
Name Vehicle License Number
Company
7. Location where contents were dis
I Vi LAJ T 9 1,2LO-7
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1