HomeMy WebLinkAboutMiscellaneous - 531 JOHNSON STREET 4/30/2018 (2) 531 JOHNSON STREET
2]D Q A-.0014-0000-0 `.
Commonwealth of Massachusetts
_ City/Town of Noah Andover
System Dumping Record
Form 4
wy DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
k with your
information must be substantially the same as that provided here. Before
n slRecord ng this must be submitted o
local Board of Health to determine the form they use.The System Pumpindate in
the local Board of Health or other approving authority within 14 days�f'o�m�tki Irl9
accordance with 310 CMR 15.351. KF_
A. Facility informati®n
important WhenTOVvi3NT
Ur NuZlh Alvi1� R
filling out forms 1. System Location: T13 �^+RTi��E
on the computer, 53 i "EAL
use only the tab 0�n S G
key to move your Address Ma 01886
cursor-do not North Andover Zip Code
use the return State
City/Town �
key.
2. System Owner: 1
i
Do-
a Name
Address(if different from location)
State Zip Code
City/Town
Telephone Number
B. Pumping Record
4 2. Quantity Pumped: Gallons
1. Date of Pumping Date
Tight Tank ❑ Grease Trap
3. Type of system: F-1 Cesspool(s) [ Septic Tank ❑ Ti 9
❑ Other(describe):
�
No If.yes, was it cleaned? ❑ yes ❑ No
4. Effluent Tee Filter present. ❑ Yes ❑
5. Condition of System:
6. System Pumped,4,
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of
Date
Hauler
Date
Signature of Receiving Facility
System Pumping Record-Page
t5form4.doc•03/06
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STEKMT S SEPTIC TANK SERVICE
)�G N)vin St, 47 RAILRQAD STREET
BRADFORD, MA 01835
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SYSTEM OWNER 8c ADDRESS YSTEM LOCATION
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DATE OF P
UMFiNC}: .4 „_Q(1ANTITY PUMPED: ,-5
CESSPOOL: NO—__-.. YES_._._._._...: SOPtic Tank: NU_..__._._.
YES .........._
NATURE OF SERVICE: KOUTINE_ ,"RUENC'Y
OBSERVATIONS;
GOOD CONDITIONP-klULL TO COVER
HEAVY OREASE BAFFLES IN PLACE:
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6XCESSIVE SOLIDS FLOODED .......
_
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COMMENTS:
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DEP has rovlded
P this form for use by local Boards of Health, The System Pumping Recora r mss:
be subinitted to the.local't3oard of Health or other a r
Pp vying authority,
nlrW r► i: nn
At .Facility Inforritlon
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only the tib key Address
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r t� of Pumping l' -�
Date 2. Quantity Pumped:
3. - ;';:,.•..: �' ;. • Gallons
Typ9 4f system ❑” Cesspools) eptic Tank ❑ Tight Tank
!.Other(descrlbe)
1�
4, E uent Tea Filter prssent?.❑ Yes o If
, yes, was It cleaned? ❑ Yes ❑ No
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Commonwealth of Massachusetts
City/Town of
System Pumping Record
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 '
ortant:
,n filing out 1. System Location: �� NOV 1 Q 2 0 11
I I
s on the /�
puler,use J()hY1)L5Qf,)
v ' VER
the tab key Address HEALTH DEPARTMENT
ove your North Andover ma 01886
or-do not Cityrrown state Zip Code
the return
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
� dog
1. Date of PumpingD � 2ate . Quantity Pumped: Gallons
3. Type of system: ❑ Cesspools) Septic Tank [ITight Tank C1Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes • , No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Stewart Septic Service
Company
7. Location where contents were disposed:
Stew Pretreatment Plant 20 So. Mill St Bradford Ma 01835
S' n reof Hauler Date
Signature o-e ing acility Date .
xm4.doc-03M System Pumping Record-Page 1 of 1