HomeMy WebLinkAboutMiscellaneous - 597 FOSTER STREET 4/30/2018 (2) Commonwealth of Massachusetts
I6City/Town ofyem � I Vit
__
System Pumping Record NORTH ANDOVCk ti �tv0\
Form 4 z
N
this form f r use by local Boards of Health. Other forms may be used,but the
provided r
DEP has 4 with your
p using this form,check y
Before
that provided
here. 9
information must be substantially the same as t p
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:
1 S
When filling out stem Location:Y
forms on the
computer,useonly the the tab key Address
to moveY our �l/ L
cursor-do not -City(Tov�n " -- - -` Slate Zip Code
use the return
key. 2. System owper.
Name
– –
�" Address if different trorfy Location)
—.
Zip Qode
City/Town G
Telephone Number
B. Pumping Record
fij- l 2. Quantity Pumped: 1� .
1. Date of Pumping ` t Gallons
Date
t1c,Tank ❑ Tight Tank E] Grease Trap
3. Type of system: ❑ Cesspool(s) p � 9 ,
❑ Other(describe): - - - -
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: �f /
ame ! Vehicle License Plumber
Company
7. Location where contents were disposed: l
Sign f H ter Date
— ---------•--- -___.__ ------ --... _
Si ature of Receiving Facility Date
15form4.doc•03106 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of, ��Q
System Pumping Record NORTH ANDOVER
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may a use ut
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 ___% e�— � �� -- - — -- --- ------ -.—..only the tab key Address
to move your
cursor-do not Cit !Town State Zip Code
use the return y
key. 2. System Owner:
v J od ,v)}_
Name --+ ------- — -- -- ---
Address(if different from location) ------------------ --,--- - ------------
City/Town ------ — ---------- -State�-74— �, ----c� !yZip Code "
g7g b33_ 0 -----
Telephone Number
B. Pumping Record L
1. Date of Pumping ✓a 7 2. Quantity Pumped: —�`�. --- --
Date �� Gallons
3. Type of system: ❑ Cesspool(s) Lld" Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): – ---- --..--_.. – --- -- ------
4. Effluent Tee Filter present? ❑ Yes ER/No If yes, was it cleaned? ❑ Yes Z'.*eNo
5. Condition ofSystem:
o,�
6. System Pumped By:
I jiy" GoOcty4�_ -76611
Name / Vehicle License Number
/' IVCx it Ylrn� �
Company
7. Location where contents were disposed:
Signature of HaulerDate
�a
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1