HomeMy WebLinkAboutSeptic Pumping Slip - 1005 FOREST STREET 3/9/2016 Commonwealth of M aSsach setts
❑RY[Town of North Andover
System Pumping Record � AL. r ; iRTl&`T
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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
local Board of Health to determine the form they use. The System Pumping Record must be submit
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 Wormation
Important:When
tilling out forms 1. System Location:
on the computer, ...M
use only the tab
key to move your Address
cursor-do not --.-----.`__
use the return North Andover
key. City/Town .. .
Stater Zip Code
2 System Owner:
lo�J rh
Name -- --° -- - ---.—-----
retan
Address(if different from location) —
City/Town ..._._..—.—......----
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Gate - -- 2. Quantity Pumped: -Gallons
3,3. 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
Signature of Hauler --- -_....___
Date
Signature of Receiving Facilty Date
(5fom4.doc-03/06
System Pumping Record-Page