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HomeMy WebLinkAboutSeptic Pumping Slip - 60 WINDSOR LANE 1/22/2016 Commonwealth of Ma�sachusetts City/Town of North Andover System Pumping Record 0 Form 4 "ED DEP has provided this form for use by local Boards of Health. Other for MITa e used, but the information must be substantially the same as that provided here Befor It in, check with your local Board of Health to determine the form they use. The System PYP,,, ",,,pst be submitted to the local Board of Health or other approving authority within 14 days in accordance with 310 CIVIR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor-do not North Andover use the return key. CityfTown State Zip Code 2. System Owner: 2C61 K'I ----------- Name sewn Address(if different from location) CityfTown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping -�_ _AAj-aa --- -------- Date Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) MSeptic 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: Vehicle License Number 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 ReceivingFacility------- Date ------ t5form4.doc•03/06 System Pumping Record•Page 1 of 1 I 1, f f. ' Y ` oF N Q R7'H'A(0OYER. S Y ST EM PUM?r.NG R�COR-D 'EM UWNFR & A0DRZ$1 �,. SYSTEM L0Ca,Tip �1 SO ...................... I.......... 1 �{ QUANTITY PUMPQD YES S'EPTIC' TANK ; N0 - ---- Y �� � �TUFtE ©.FSERYICE; ` ROUTINE. EMERCENCY 1 ' uIJ>�fZY;�'l'10�(51 V xY G'C,(�NU.ITION FULL.TU C O Y Ek 1'hl .r1`�!Y,Q,h�E-A C- r' ' ' l3aFFLLS IN I l,aCl' LEACHFIE L iturruA( ., CXCESSIYEOl�lDS : FLOODED' CAgqRIR)YOYER ,p HRR (EXf'1,A.lN) t ;){, !�IJIti yl'�(RI,�Y kNt1�'�/bijr;t(.X{I }l1j1,IVL r•I°�I 1 P l +,tl'6 0 1,1 .., :ir' �1'S'I'l'M 'PIUM:PC<5 oYi.,. CU.)i�y.I rNTSI,, t {,�•�y I.S I�syi I I ',I 0111�,I1t!t<<ll.'71�1�I�t�,. , n u� J�*.R D :TQ; tG' r' r O��rA1a0VER 1ASSACHu ,�!1'��,Y,ir� �'I4�f"4'11�'I�11�'!•'•., ,t•. ���i,.l\ r: eP.hoI Pit Yldod Ihlo torfn r?f yq or 6oarc RECEIVE 0o I'.vn`rllod to (Av lour 8cert: rr or nq8':� � ( .�I a I q' of cu,of Pa ,r �...' n n A. Faclllty Inform -a ftn AN HEALTH DEFIARTMENI' Tim SMOrf1 . .Y ♦/I / .Il,�rlrrl r 'I!)��,1;1.`;1' � ry• �'�I r' .A '' �' '�drµ+ (IIOV(Irrnl rp�n buVvn) . rl�lpngnl n,mgl, — %.gt' P,umpIng Ray.ard t•r',.,� •i' 1 ' oel� o' P 'mpin , Yp� 9� i il9 C9 9Poow r, . DI•C Ton, r h1V9(1I r99 F111o(,P(,Q,)onrl r' Yo9 C no u ,,, 4.•,'.1',�����0,7•�t�����'','(r;/,'!�,�;;! 1'lrr4',,, ,t, y69 n9) IIC'9anaQ� � Y� c l Colidiyon . , • ' 9, ' Sy py�mpcd'8�y,, ' • it, ull{ YInIV, /UyG4n+l r S''' :r\'`, `r•ya`I, � (''f',t,�Y,,�� li Go, an ,w, is dlyposaa: ..,, rr'�rw.m65J,goYl dBjY`W81�er lapproYaJs%Iblorm�.n:malns�acl