HomeMy WebLinkAboutSeptic Pumping Slip - 1430 GREAT POND ROAD 2/9/2016 _ commonwealth ®f 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 Information
important:When
fMing out forms 1. System Location: r
on the computer,
use only the tab .4. --T -`.'
key to move your Address - '- . -------- ----- --•---
cursor-do not North Andover
use the return —____-•.._.,_,-,•,
key. City/Town State Zip Code
2. System Owner: z
Name -- --- ---- --- ------
ienun
Address(if different from location) --
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping -- 2. Quantity Pumped:
Date y p 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:
d
6. System P d By:
Name Vehicle License Number
wart's Se tic Service
ompany
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler -.__- - -- ---- ---._...___.-._........._. .
Date
Signature of Receiving Facility "' "
.6a.te .._...._.._.
t5form4.doc-03/06
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