HomeMy WebLinkAboutSeptic Pumping Slip - 369 SALEM STREET 12/6/2010 }
Commonwealth of Massachusetts r
VE
City/Town of
System i iUi 0 ` II
Form 4
TOWN OF NCRTH AM) VF
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other f us , ut 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
�o�ant:
en filling out 1. System Locatio_
ns on the r -
nputer,use
r the tab key 'Address
nove your North Andover ma 01886
sor-do not City/Town State Zip Code
the return
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
l / S
1. Date of Pumping Date 2. Quantity Pumped: Gauons
3. Type of system: ❑ Cesspools) ptic 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
r),—) Inc–c-
ame Vehicle License Number
Stewart Septic Service
Company
7. Location where contents were disposed:
St warts Pre atment Plant 20 So. Mill St Bradford Ma 01835
Signature o Hauler Date
Signature of Receiving Facility Date ,
xm4.doc-03M System Pumping Record•Page 1 of 1