HomeMy WebLinkAboutMiscellaneous - 270 BRADFORD STREET 4/30/2018 (2)-4
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Commonwealth of Massachusetts
City/Town of North Andover
o
System Pumping Record sp I a
Form 4
TOWN OF NOWN AND'
DEP has provided this form for use by local Boards of Health. Oth 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.
City/Town
M a
State
State
Telephone Number
B. Pumping Record /
1. Date of Pumping bate— 2. Quantity Pumped:
3. Type of system: Cesspool(s) J;��eptic Tank E] Tight Tank
F� Other (describe):
4. Effluent Tee Filter present? 0 Yes E] No
5. Condition of System:
6. -S"tem umpe y:
�
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treCrfteq
Klant, 20 So. Mill $�adfo
Sign
acility
01845
Zip Code
Zip Code
Gallons
0 Grease Trap
If yes, was it cleaned? F� Yes 0 No
Vehicle License Number
rd, Ma 01835
Date
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
A. Facility Information
Important:
When filling out
1 . System Locatiorx.
forms on the
2
computer, use
7 r)
only the tab key
Address '--
to move your
N.Andover
cursor - do not
City/Town
use the return
key.
2. Owner:
—Sxatern
Name
Address (if different from location)
City/Town
M a
State
State
Telephone Number
B. Pumping Record /
1. Date of Pumping bate— 2. Quantity Pumped:
3. Type of system: Cesspool(s) J;��eptic Tank E] Tight Tank
F� Other (describe):
4. Effluent Tee Filter present? 0 Yes E] No
5. Condition of System:
6. -S"tem umpe y:
�
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treCrfteq
Klant, 20 So. Mill $�adfo
Sign
acility
01845
Zip Code
Zip Code
Gallons
0 Grease Trap
If yes, was it cleaned? F� Yes 0 No
Vehicle License Number
rd, Ma 01835
Date
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1