HomeMy WebLinkAboutMiscellaneous - 507 JOHNSON STREET 4/30/2018 (2) I
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Commonwealth of Massachusetts
City/Town of No.Andover
o System Pumping Record
Form 4
N Sve
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 fro
accordance with 310 CMR 15.351.
A. Facility Information DEC 011
Important:
When filling out 1. ANOVI A VA
forms on the
NQALTH MPART OW
computer,use )Ohn("
only the tab key Address
� t
to move your 1 No.Andover Ma 01845
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
t4Q 6)0 Kf
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingDat — - 2. Quantity Pumped: G&Iions
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �Oif yes, was it cleaned? ❑ Yes loo
5. Condition of System:
6. SyStern Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Sign ure o a ler Date
Si atu of ceiving Facility Date
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8,. `,Type pf ayatam , ❑ Cesspools) eptic Tank ❑ Tight Tank
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httpJ/www:mas's.gov%dapJwater%appr'ovaJsWormsNiTi Inspect
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System Pumping
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