HomeMy WebLinkAboutSeptic Pumping Slip - 290 BARKER STREET 10/28/2015 Commonwealth of Massachusetts
City/Town of North Andover
System upin 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. (4,"
A. Facility Information
Important: Tk ANN Oi 6�OTT'°A i /I&iP:ri'�7'JER
When filling out 1. System Location:
forms on the H F,AL1 d P CrI C �4I�9 ill `dN
computer, use 290 Barker
only the tab key Address
to move your North Andover Ma 01845
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
11 r6 Lindquist
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 5/23/11 1500
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:
Good Condition
6. System Pumped By:
Bruce Merrill
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart Is Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
ISignature Peiving Dane —
Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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:'DER,has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted tothe local Board of Health or other approving authartty, 1
'
A Facility Informlation
'-important
yVheri filling out 1 . System Location, ;
forma.on the f
40 - �
computer,use �,•• �, 6 � r
only the tab key Address '
to move your � <
cursor•do Prot CI
use the return ty/Town State dip
Code
keY
s 2r System Owner; r
t t
Name }
Address(if different from location)
Citylrown $tat
Zip Code
Telephone phone Number
B 'Pumping Reco rd.
Date of Pumping pate 2r Quantity Pumped; —�D .
Gallons
3, Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑'Other(desGribe), o
4 Effluent Tea Filter present?, Yes,❑ No* If yes, was it cleaned? ❑ Yes ❑ No
�s
S Condition of 8yit9p
6 Sy em Pumped By'. '
,G
Name Vehicle License Number
t r. t tii.l r rirt iktti ft1'�;r'�� I.n I46 '�%I
:: Company. , t,, r { ,,,.•, J '
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7 'L;ocatJon where t otntents were disposed:
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} 1 Signature of Hauler„, t. Data
httpJ/www mass gov/deptwatsr/apprpvals/t5farms,htm#inspect
t5form,4.doc••06/03
System Pumping Record Page 1 of 1
Commonwealth of Massachusetts RECEIVeD ti�
ityjown of No Andover JUN
System pin Record ) n
Form 4 TO H OF H P4'rl-1 ANDOVER
Hi p
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 " ! C.
key to move your Address
cursor-do not No andover Ma
use the return City/Town/Town
key, y State Zip Code
2. System Owner:
VQ
Name
ream
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date / 2. Quantity Pumped:
Gailons
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. Conditioof System:
6. Sy mped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewkt'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
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