HomeMy WebLinkAboutMiscellaneous - 90 WINTERGREEN DRIVE 4/30/2018 (3)0
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IC -N Commonwealth of Massachusetts
W City/Town of No.Andover
a W° System Pumping Record
Form 4
M
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. S tem Location:
forms on the
a)
computer, use
-
only the tab key
A dress
to move your
No.Andover
cursor - do not
City/Town
use the return
key.
r�
2 System Owner:
Alf
Name
Address (if different from location)
City/Town
_ Ma
State
State
Telephone
01886
Zip Code
Zip Code
B. Pumping Record TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
1. 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
5. Condition of System:
6.i �ed By-
Mt-
:
_5
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
I W�� 10 V/ e;L—
Signature of Receivin a ility Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
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