HomeMy WebLinkAboutMiscellaneous - 65 Stonecleave Road PL
May 10 11 11:34a p.3
Commonwealth of Massachusetts ..
-. City/Town of Boxford RECEIVED
a► System Pumping Record < <
For ` P�A 2011
TOWN N TH ANDOVER
SEP dorms may e W=&' 6 ARTMENT
info �� ore using
focal - _ _ - - - - roping Record must be submitted to
the lot rorn the pumping date in
66 in
Important:
When filling out 1. SA —
forms on the -1A- p
computer,use -1- `/�� r�
Ao (y� -- _
only the tab key
to move your
cursor-do not � ` O x Zip Code
use the return Cit
key.
z. s
Nai _ ---
Ad
Zip Code
aty - L
B. Pu
I Than_
1. Date �' Gallons
3. T pI- - - . - - - - -- - t Tank ❑ Grease Trap
❑ _ ---
4. Efflu __ _ - -- - ------- — aned? ❑ Yes ❑ Flo
5. Conk- ---._--- - -._ - -- -- - - - - - --- -- - -- ._
6. 0MnAqC___
Vehicle License Number !fl
Stewart's Septic Service
Company
7. Location where contents were disposed: f1J �
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 018350,^-;R'
Signature of Hauler — Date —
Signature of Rec ivin,I Date
System Pumping Record•Page 1 of 1
t5form4.doc•03106
9783736611 05/10/2011 09: 22 RECEIVED FROM: #1730-003
May 10 11 11:34a p•3
Commonwealth of Massachusetts
-
City/Town of Boxford RECEIVED
' '►
System Pumping Record
Y HAY I � 2g99
Form 4
.. 70WN,�F N��Q TH ANDOVER
DEP has provided this form for use by local Boards of Health. Other farms may e �,,t t Tit RTMENT
information must be substantially the same as that provided here. Before using r ,
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
I m portant:
When filling out 1. Sy tern Location:
forms the
computer,use
only the tab key Address �y�p ,(�'
to move your l)V eV Ma
cursor-do not City/Town State Zio Code
use the return
key. 2. System Owner:
1
Name
Address(if different from location)
CitylTown
S ate Zip Code
Telephone Number
B. Pumping Record
R1. 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:
Cf� -
6. S stem Pumped B
Lt v,
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed: 7r% b'�"FO'RD
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 (�AF.
=�i_g_natureauler Date
�L-{ I 1
Signature of Pec ivin I Date
System Pumping Record•Page f of 1
t5form4.doc•03106
9783736611 05/10/2011 09:22 RECEIVED FROM: #1730-003