HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 1/1/2012 Commonwealth of Massachusetts
o City/Town of North Andover
System in Record 4 � ,
a
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 authority 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, "�J c
use only the tab _s.„,.,m'
key to move your Address
cursor-do not North Andover Ma 01845
use the return -
key. City/Town State Zip Code
2. System Owner: -
�
Name
�rwn
Address(if different from location)
Cii /Town Y State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - / 2. Quantity Pumped:
mate 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:
6. System Pumped y:
Ci r ► , c
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
Srgnatur
e of Hau a Date
Signature o ecewi mmm
g ing Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
I rt i.
Commonwealth of Massachusetts
City/Town of North Andover " 1� 13
' ) 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 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
Important:When
fillip out forms 1. System Location: ,. ❑ rµ°
g Y
on the computer, -. t� ^ � � �❑, �
use only the tab ^— ❑
key to move your Address
cursor-do not North Andover Ma 01845
use the return
key. City/Town State Zip Code
2. System Owner: .r
tab
Name
rerwn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
Quantity �
1. Date of Pumping
Date 2. y Pum p ed: Gallon on s
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:
(S:x-_w
em Pumped By:
V-A. t,
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
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of North Andover
Pumping System r
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 authority within 14 days from the pumping date in
accordance with 310 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location'.
on the computer, r
y _ t�
use only the tab .. � � � )
key to move your Address —
cursor-do not north andover
use the return --- Ma
key. City/Town State Zip Code
�� y
2, System Owner:..
Name
re�an
Address(if different from location)
north andover
City/Town State Zip Code
Telephone Number
B. Amin r
1. Date of Pumping Date 2. Quantit y Pumped:
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:
_ ❑
6. System Pumped By:
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
g Date
Signature of a
Signature of,Receiving Facility Date
t5form4.doc^03/06 System Pumping Record•Page 1 of 1