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Commonwealth of Massachusetts R CE d
City/Town of No Andover
System Pumping Record JUN 10 2013
i` Form 4 TOWN OF NORTH ANDOVER
LI AL N. DEPARTMENT
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 forms 1
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key-
4:1 :I 2
ova
t5form4.doc• 03/06
System Location:
Wo Fres r
Address
No andover
Cityrrown
System Owner:
ala r7
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system:
❑ Other (describe)
Ma
State
State
Telephone Number
Zip Code
Zip Code
L--2_12.
Date Quantity Pumped:
Galles
❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes V No
5. Condition of System: (
If yes, was it cleaned? ❑ Yes ❑ No
6. Sy st ed By:. --
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Afe'�art's Pre-treatment Plant, 20 So. Mill Bradford. Ma 01835
of Receiving Facility
Date
Date
System Pumping Record • Page 1 of 1
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Commonwealth of Massachusetts
W W City/Town of No. Andover JUL $ Hill
TOWN OF NORTH ANDOVERS stem Pumping Record
HEALTH DEPARTMENT
4fM SV a y`
Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
tcl
iemm
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
1. System Location:
Address
No.Andover
City/Town
2. System Owner: I
S
Name
Address (if different from location)
City/Town
Ma 01845
State
State
Telephone Number
B. Pumping Record b!I
1. Date of Pumping Date ' I 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System: n ond
6. S stem Pumped By:
JC4e
ame
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treant Plant, 20 So. Mill Bradfoi
Signatu fd/q Hauler
Receiving Facility
Zip Code
Zip Code
Ino n
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
Ma 01835
Date
Date II�U
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1