HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 1/11/2016 I
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
local Board of Health to determine the form they use. The System Pumping Record must be submitte
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: I "�� i ?!.1 I IF,
on the computer,
use only the tab
Cam ( Y i0:
key to move your Address -- --••- -----
cursor-do not 1•I"
use the return North Andover
C' /Tow
key. � n State Zip Code
2. System diner: r,
-� , Le � v
Name _ --- -- - --- ------
ie2mon
- ......_................._ .._. _. . -
Address(if different from location-).— - "-'---"--- -°--°-----°---
City/Town State 'Z'-i,
ip Code
- Telephone Number •
B. PUMPing Record
1. Date of Pumping Date i !' - 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:
-- -- � v
6. System Pumped By:
------—---
—
Stewart's Septic Service Vehicle License Number
Company —._._........_..._ .
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of
"
Signature of Receiving Facility
t5form4.doc•03/06
System Pumping Record•Page 1 o
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 yo
local Board of Health to determine the form they use. The System Pumping Record must be submitted
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 Informed®n
Important:When
511ing out forms 1 System Location:
on the computer, j
use only the tab
key to move your Address
cursor-do not
use the return North Andover
key. City/Town State 77-
fp Code
2. System Ow er: 'n
Address(if different from location)
City/Town ......
State Zip Code
Telephone Number
B. Pumping Record
-16 _,
1. Date of Pumping . .L�........ 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
Stewart's Septic Service Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of�Hauler ------
Signature�of Receiving Date ...........
t5form4.doc-03/06
System Pumping Record•Page 1 of 1
�
commonwealth of Ma,,�sachusetts
City/Town of N rth Andover
System �
^
��u00� �� �����_� '
` . ~�
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 aathat provided here. Before using this form, check with yo
local Board of Health to determine the form they use. The System Pumping Record '~~^be submitted
the local Board of Health or other approving authority within 14 days from the pumping in
accordance vvith31OCPNR15.351, " -~ �
. . ` A. Facility xxxooxuxxatHo0!
Important:`
ulling out forms t ]6N 1 1 7D1�on�e ���| /| �--- ""'`
use only the tab _]��.jO=��` :
�you move�mr -'---'----'-
xov�sa ����T���T����-_����:T -----------------
cursor-uonm '
use the return '~^"''" d""=
key. cny/To�n �-'--- ------ ���'---------- --���--------'
�
2. System Owner:
mame / ~ / -- ---'- -- -------------------
Addreos(if—different fror� �Vnn ----------' -' '-- ----'------------ |
_-_-_�---___ __. |
un«/own ���'------------
Telephone Number
B. Pumping Record
1. DateofPumping l��� 2� Quantity Pumped: -
3. Type ofsystem: M Cesspool(s) /'Septic Tank Fl Tight Tank El Grease Trap
LJOther(describe): --------'-'-�_` '�-__-____---__---'_'--_-_
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? D Yes Fj No
5. Condition ofSyatem� ^^
/ �_-------------------.............
------
-_~--
h� 'System Pumped By: ~--~
mame /' �------- T����---------------- �
Stewarrs Septic Service` License Number ��--'----
Company
----- -'- '— |
7. Location where contents were disposed:
"=,,a.tur/u-u�m�mmnzPlant, 20 So. Mill Bradford, Ma
x,qnamrevrVauwy ��--�---------' --------'-- ' -----
oo� ���-------
oignamrenf�eoe�ng�ao � --' -- - - '--' ����e---- '---'- ' ---------------
mfom4.um,03m6
System Pumping Record'Page Iof1