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Home My WebLink AboutSeptic Pumping Slip - 351 WILLOW STREET 10/19/2015 Commonwealth of Massachusetts H -- City/Town of North Andover System Pumping Record Forma 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 forms 1. System Location: on the computer, g use only the tab t -I M0 _._ ' key to move your Address - ---- --- — - - - -. . ----------- -- cursor-do not North Andover use the return key. City/Town State Zip Code 2. System Owner: Name - ietran Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping ate - �2. uantity Pumped: _ - Gallons 3. Type of system: ❑ Cesspool(s) L4,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: ff\\\\\\(( 6._- System Pumped_,By: - -------- --- -------- ------- ...— — 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 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 _ Commonwealth of Massachusetts City/Town of North Andover 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 forms 1. System Location: on the computer, use only the tab U � ---�� ----------�_----------------- key to move your Address cursor-do not North Andover use the return --- key. City/Town State Zip Code 2. System Owner: Name rerrun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping — - �- -- Quantity Pumped: - --- 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 System: 6. System Pumped By: Narne -~- =- Vehicle License Number - - LS#ewart's`Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of'Massachusetts - City/Town of North Andover System Pumpong 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 forms 1. System Location: on the computer, r�f A C use only the tab U 1 1`� ` key to move your Address cursor-do not North Andover use the return --- key. City/Town State Zip Code 2. System Owner: s; Name ienvn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping - - - - 2. Quantity Pumped: - 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 System: - ,------------------ 6. System Pumped By: `-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 Signature of Hauler Date .--......- ---- Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 _ Commonwealth of Massachusetts H - City/Town of North Andover 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 forms 1. System Location: r on the computer, use only the tab - key to move your Address cursor-do not North Andover use the return --- key. City/Town State Zip Code 2. System Owner: ; Name rerron Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping D -- a-- 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: - — -- - --- - - - --.-_.............. - - --- 6. System Pumped By: _ Name``- Vehicle License Number G Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts --- City/Town of North Andover 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 forms 1. System Location: on the computer, YAQ \Aw use only the tab . - -- -- -- - -.. . . - - ---- -- key to move your Address cursor-do not North Andover use the return — — -- -- -- _._. - - -- - ---------- key. City/Town State Zip Code 2. System Owner: Q Name Address(if different from location) CityfTown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping `-ate �v.Q_�2. Quantity Pumped: Gallons ax 3. Type of system: ❑ Cesspool(s) USeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): --- -- --- ------- _ ---- -- - -- 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No r 5. Condition of System: C 6. System Pumped By: - _ _ — ---- - - --- ------ ------------------- Name ~-"~-`-`- ��e�icle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1