HomeMy WebLinkAboutMiscellaneous - 42 SUMMER STREET 4/30/2018 (2) 42 SUMMER STREET
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Commonwealth of Massachusetts REM ED
City/Town of No. Andover �� � Qgt
a System Pumping Record
�1A� 0
Form 4 TOWN OF NORTH ANDOVER
,M 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 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use 42 Summer st
only the tab key Address
to move your No. Andover Ma 01845
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
r� Tylus
Name
fe"tlA Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 4/19/11 2. Quantity Pumped: 1000
Date Gallons
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:
Good Condition
6. rm Pumpe
Name Vehicle License Number
Stewart's Septic Service
Company
i
7. Locati n w ere contents were disposed:
St ' Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 i
i � 1
Snatu auler Date'
Signature of Recei in Facili y Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
W City/Town of No. Andover
a
System Pumping Record 1ripii
Form 4 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 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use 42 Summer St
only the tab key Address
to move your No. Andover Ma 01845
cursor-do not
use the return City/Town State Zip Code
key. 2 System Owner:
r� Tylus
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
4/6/11 1000
p g Date 2. Quantity Pumped: Gallons
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:
Xsolids
6. SRtem Pu By:
Knu ��a�z CD
Name Vehicle License Number
Stewart's Septic Service
Company
7. Lo ati n where contents were disposed:
Sew rt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
ignature o Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1