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Commonwealth of Massachusetts
AN -W City/Town of North Andover
ytem Pumping Record
Form 4
wy 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. Beforeusing
this (must ch submitted o
with your
local Board of Health to determine the form they use. The System Pumping date .s
the local Board of Health or other approving authority within 14 days from the pumping p 9
in
accordance with 310 CMR 15.351.
System Pumping Record - Page I
t5form4.doc• 03/06
A. Facility Informati®n
Important When
forms
y
1. System Location: 1 ;
Cob
' V-
onout
on the computer,
use only the tab
key to move your
Address
Ma
01886
cursor- do not
North Andover
State
Zip Code
use the return
City/Town
key.
2. System Owner: kA
a
Name
rim
Address (if different from location)
State
Zip Code
Cityrowh
'
Telephone Number
'B. Pumping Record
fob
Cl
!e
2 Quantity Pumped:
Canons
1. Date of Pumping D
i� 9'2015(�
Septic Tank E] Tight Tank
E] Grease Trap
h f td �
3. Type of system: ❑ Cesspool(s)
�®
❑ Other (describe):
❑ No
Effluent Tee Filter present? ❑ Yes ❑ No If.yes, was it clearied?
❑ Yes
4.
5. Condition of System:
6. System Pum
vehicle License Number
N
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So.
Mill Bradford, Ma 01835
Date
Si n u er
Signature of Receiving Facility
Date
System Pumping Record - Page I
t5form4.doc• 03/06
I
Commonwealth of Massachusetts
City/Town of No Andover RECEIVED
System Pumping Record ;1�iY i 9 2014
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Hea#..�GTfrF^4r a�._yr&N r�—R4 e_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
Important: When
filling out forms 1. System Location:
on the computer, C /
use only the tab 5 f� �U Y� ,Q I
key to move your Address
error- do not No Andover Ma
use the return
key. City/Town State Zip Code
2. System Owner:
Name
mavn
Address (if different from location)
City/Town State Zip Code
17
B. Pumping Record
1. Date of Pumping
3. Type of system:
Telephone Number
!� bate 2. 2. Quantity Pumped:
❑ Cesspool(s)
❑ Other (describ"
e):
❑ S is Tank Tight Tank
4. Effluent Tee Filter present? ❑ Yes. No
5. Condition of
f. D+
allons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
6. System Mpd By:
2 � --
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
Date
Date
System Pumping Record • Page 1 of 1
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OERhas provided �hls form for use by local Boards of Health, The Sysiem Pumping
Recti _
be subml1�edLto:the I•ocal Board of Health or other approving authority,
> .,:..
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_ Dole 2' Quant! ry Pumped:
.r Tank vf.a•. ,319111' ,
y.. 0 Cesspools) Septic T ❑ Tight t.' .,') •, :.:;,` ; f Tank
.V � 1/,15i��1 i'ii/�i 1i�jl+i'1 �i'I'il:;.u', r"•1,•f!' v.
Effluent Tee Fille(' resent? ❑ If
'+);:il;! „1,:: ;h p ❑ Yes No yes, was It cleaned? ❑ Yes ❑ No
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.. ,_ �ptY'�rtt7;::y,:'�;i4,'It'�afllrl\''.�,i•
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�-L\ 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
Important
When filling out 1. System Location: W5)
forms on the W' (� n
computer, use
only the tab key Address
to move your North Andover ma 01886
cursor - do not City/Town State Zip Code
use the return
key. 2. System Owner: RO
HP IV
A An
.101
Name AUG —5 Z011
Address (if different from location) TOWN OF NORTH ANDOVER
EA
City/Town State
Telephone Number
B. Pumping Record -
1. Date of Pumping Ll 2. Quantity Pumped: /00ci
Date / Gallons
3. Type of system: ❑ Cesspool(s) 52 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
6Cyt
Name
Stewart Septic Service
Company
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
7. Location where contents were disposed:
S"ewara.Pre treatment Plant 20 So. Mill St Bradford Ma 01
Signature of Ham�'
Signature of Receiv ni g Facility
Date 7.11
Date
t5form4.doc- 03/06 System Pumping Record • Page 1 of 1