HomeMy WebLinkAboutSeptic Pumping Slip - 197 BRIDGES LANE 12/28/2015 I
II
Commonwealth Of Massachusetts ,,,,
City/Town Of No Andover
H
0
w System Pumping Record,
Form 4
s
DEP has provided this form for use by local Boards of Health. Other form: 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, 1
use only the tab 97 Bridges LAne
key to move your Address
cursor-do not No Andover MA
use the return — _ -------- -____ _ ..___--.------ ---- —
key.
City/Town State Zip Code
2. System Owner:
Higgins
Name
ietisn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: al ns
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 ystem:
5
6. S y s t e M 4 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 _
�ignat re Hauler
+,of Date
Sig ature o e Fai„„
4�.... -- Date — -----
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System Pumping Record•Page 1 of 1
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be submitted to the.local'Board of Health or .ot� dap rgvin autho ity,
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TO" OF NORTH ANDOVER N(j) 4 2 0
SYSTEM PUMPING P-ECOR
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I'E)/l OWNER & ADDRESS
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team e°E OF PUNIPINC:. QUANTITY P U M L D
1'0 0 L: NO YES SEPTIC TA N K NO y
I URE OF SERVICE: ROUTINE EMERGENC�,
F f V ;\T 10 N S:
COOD CONDITION FULL TO COVEIIZ
HFAVY CREASE BAFFLES IN P1,AC!"
ROOTS LEACHFIELD RI—N.13ACK
EXCESSIVE, SOLIDS FLOODED
SOLIDS CARRYOVER O,�HER (EXPLAIN)
I L M P U N1 1)E D B Y
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