HomeMy WebLinkAboutMiscellaneous - 328 CAMPBELL ROAD 4/30/2018 (2)IN- Commonwealth of Massachusetts
rCity/Town of No Andover
System Pumping Record
M SV
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 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 328 Campbell St
key to move your Address
cursor - do not No Andover MA
use the return — — —/ 7.S
key. City/Town State Zip Code
2. System Owner:
Hickey
Name
Address (if different from location)
City/Town State Zip Code
6017 7o)1 960
Telephone Number
B. Pumping Record
1. Date of Pumping Date J� 2. Quantity Pumped: Ga�
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: I
L, 'j '�' "-v ,
6. System Pumped By:
Name
Stewart's Septic Service
Company
_ter-�• ' �' ;;i
Vehicle License Number r� '
vb.,
�2TH AtyDDVER ',
YD�'t;i DF r`�cpp,FtT���ENY
HEALYN
7. Location where contents were disposed:
Stewarts fre-treatment Plant. 20 So. Mill Bradford. Ma 01835
of Receiving Facility
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
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ty
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Commonwealth of Massachusetts
City/Town of No.Andover
System Pumping Record
M Sye e
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.
VQ
IL 0
rertan
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
No.Andover Ma 01845
City/Town State - . - , ,� �fpd"
2. System Owner:
JAN I U ZU1z
Name
TOWN OF NORTH ANDOVER
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. QuantityPumped:
Date allons
3. Type of system: ❑ Cesspool(s) �SepficTank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes �No If yes, was it cleaned? E] Yes ❑ No
5. Condition of Sys 1:4.,
6. Sped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
S art's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
( (te
Signature yofHauler Date
�Signature,of Recei� Facility _ Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1