HomeMy WebLinkAboutSeptic Pumping Slip - 105 WINTERGREEN DRIVE 2/25/2016 Commonwealth of Massachusetts
W City/Town of No Andover
System u in 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 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 au'hority 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:
on the computer,
use only the tab ____________
key to move your Address
cursor-do not No Andover Q Ma 01845
use the return --------------------- -
---------------------- ------------
key. City/Town State Zip Code
2. System Ow e
*CIA ... . U1 a
--- -- - -
Name p I ry VV / p
elwn Jdj4 t N d�)
Address(if different from location)
Id��fl(��:,:Ml I!C)ii"lR6Elil��}\/hlr
City/Town State Zip Code
Telephone Number
B. Pumping Record
' ---- -
1. Date of Pumping Date= , Quantity Pumped: Gall ns
3. Type of system: ❑ Cesspool(s) ,2 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? El Yes If yes, was it cleaned? ❑ Yes —Nb
5. Condition of System:
�.
6. Syste ..Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pr -treat ent Plant, 20 So. ill-Bradford, Ma 01835
Signatur of Ha ler Date
Signat f ec iva q facility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
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