HomeMy WebLinkAboutSeptic Pumping Slip - 35 EVERGREEN DRIVE 2/9/2016 Commonwealth of Ma�sachusetts
❑itLy/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 I
information must be substantially the same as that provided here. Before using this form, check wi
local Board of Health to determine the form they use. The System Pumping Record must be subm
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Wormation
Important:When
,illing out forms 1 System Location:
"'o
on'the computer, J)
use only the tab 15 1
CA)e
key on move your Address
cursor-do not
use the return North Andover
key. City/Town State Zip Code
4
2. System Owner:
'Name
Address(if different from location)
City/Town State........ Zip Code
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ ight Tank ❑ Grease Tri
❑ Other(describe): —-----
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-,
6 System Pumper
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
Signature of Hauler Date
lgnatUre
of
'Vi;]�g
Facility Date
t5forr,4.doc-03/06
System Pumping Record•Page