HomeMy WebLinkAboutSeptic Pumping Slip - 575 WINTER STREET 3/14/2016 Commonwealth of 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 dform,
must check with your r be
local Board of Health to determine the form they use. The System Pumping in date in
the local Board of Health or other approving authority within 14 days from the pumping
accordance with 310 CMR 15.351.
A. Facility lnformation
important;When
System stem Location:
Oiling out forms Y
on the computer,
use only the tab AC-
key to move your Address Ma 01886
cursor-do not North Andover State Zip Code
use the return City/Town
key.
&❑ 2 System Owner:
C
Name
raven
Address(if different from location)
Stale Zip Code
Cityrown
Telephone Number
B. Pumping Record „
2. Quantity Pumped: Gallons
1. Date of Pumping Date
Tight Tank Grease Trap
S tic Tank ❑ g
3. Type of system: ❑ Cesspool(s) ❑
e
p
❑ Other(describe):
If. es, was it cleaned? Yes ❑ No
4. Effluent Tee Filter present? ❑ Yes E] No y
5. Condition of System: 1
6. ,y tem Pumped By
.... Vehicle License Number
-Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart -Pre tment Plant, 20 So. Mill Bradford, Ma 0 835 2
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kk is y�I�et�
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Date rytt �,,i r
Signature of
�µ ,oe 0 ing Fac l - Date
re ity
System Pumping Record Page
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