HomeMy WebLinkAboutMiscellaneous - 480 SHARPNERS POND ROAD 4/30/2018 (6) i L'S Commonwealth of Massachusetts
CityfTown of
System Pumping Record
Form 4
DEP has provided this Than 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
ortant:
.n filling out 1. System Location:
p to the PC
Weer,use
the tab key Address
'on your North Andover ma 01886
or-do not City/Town State Zip Code
the return _
2. System Owner. RECEIV D�
bum
Name AUG
Address(if different from location) TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 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: h
U .
6. S m Pumped By:
Name Vehicle License Number
Stewart Septic Service
Company
7. Location where contents were disposed:
Stewarts Pre treatment Plant 20 So. Mill St, Bradford Ma 01835
Signature of Hauler Date
N --7I 0
Signature of reoeMng Facility Date
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