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Commonwealth of Massachusetts _
City/Town of No Andover RECEIVED
a System Pumping Record °
Foam 4 AUG o 4 2014
Y
Q,
1 TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other (r>'rir'e�lt,th
information must be substantially the same as that provided here. Before using this farm, check with your
local Board of Health to determine the form they use. The System Pu aping Record must be submitted to
the local Board of Hwalth or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
City/Town Mate Zip Code P ^ F
Telep'ione Number A .T
B. Pumping Record
1. Gate of Pumping 2, Quantity Pumped:
Gallons
3. Type of system: 0 Cesspool(s) eptic Tank R Tight Tank Grease Trap
Other (describe):
4. Bffluent Tee Filter present? [] Yes M No If yes, was it cleaned? [I Yes jr] No
5. Condition �I of Systom:
6. System Pumped By:
Na ks Vehicle l=icense Nuftr
Stewart's septic Service
Oompany _ _
7, Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
ignature of Hauler �`..�.,�,.._•`` `.._.�-"""-,�.�
tate _
urs of a ceving Facility _ _ �.. [ate
t5form4.doc 06 System Pumping Record ° Page 4 of 1
A. Facility Information
Important: When
filling out forms
on the computer,
1 • System Location:
use only the tab
key to move your
Address
4
cursor , do not
no Andover
M,A
use the return
key.
City/Town
State Zip code
2. System Owner:
sa ienza _
Bnvn
Name
_
Address (if different from location)
City/Town Mate Zip Code P ^ F
Telep'ione Number A .T
B. Pumping Record
1. Gate of Pumping 2, Quantity Pumped:
Gallons
3. Type of system: 0 Cesspool(s) eptic Tank R Tight Tank Grease Trap
Other (describe):
4. Bffluent Tee Filter present? [] Yes M No If yes, was it cleaned? [I Yes jr] No
5. Condition �I of Systom:
6. System Pumped By:
Na ks Vehicle l=icense Nuftr
Stewart's septic Service
Oompany _ _
7, Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
ignature of Hauler �`..�.,�,.._•`` `.._.�-"""-,�.�
tate _
urs of a ceving Facility _ _ �.. [ate
t5form4.doc 06 System Pumping Record ° Page 4 of 1
Commonwealth of Massachusetts RECEIVEC
W City/Town of No. Andover ��L 1$ 011
a System Pumping Record
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
�Q
sewn
Form 4 TOWN OF NORTH ANDOVER
HEALTH 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
1. System Location:
Address
No.Andover
City/Town
2. System Owner:
I
Name
Address (if different from location)
Ma
State
01845
Zip Code
City/Town State Zip Code
Telephone Number
B. Pumping Record Ld
Iy p1. Date of Pumping � (2. Quantity Pumped: ��l
Date 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 Syste
6.Vame
m Pumped By:
Stewart's Septic Service
Company
Vehicle License Number
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
�ature of Hainer
Signature of Receiving Facility
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1