HomeMy WebLinkAboutSeptic Pumping Slip - 35 MARIAN DRIVE 3/16/2016 Commonwealth of Massachusetts
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System Pumping urn in Record ru,� �, �r G�,ti
Facility Information:
System Location:
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Address
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City/Town State Zip Code
System Owner:
Name:
Adress (if different from location of pump)
City/Town State Zip Code
Telephone Number
Pumping ecor
Date of Pumping.. Quantity Pumped_ x gallons
Type of System a'° Septic Tank Grease Trap Other (what)
System Pumped by: ,,
Company: ROOTER-NIAN 46 Portland Street Lawrence, MA 01843
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Location where contents were isposed r"
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Signature of Hauler Date ,°: �
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Commonwealth of Massachusetts
City/Town of North Andover � T��Wrl��d� ���rlau �f��rcl��� R
a System Pumping rd
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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 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, _ l
use only the tab \\\`w•, ❑
key to move your Address
cursor-do not North Andover Ma 01845
use the return - - —
key. City/Town State Zip Code
2. System Owner:
fEe ..
Name
fEIWII
Address(if different from location)
—.
City/Town State Zip Code
Telephone Number
B. Pumping ecor
1. Date of Pumping 2. Quantity Pumped:
Date 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:
CCU r 1- -1. , (�
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart.'s-Pretreatment Plant, 20 So. Mill Bradford, Ma 01835
Ln natu of Railer.__... _ [sate - —
Sign re f Receiving Facility Date- - E- ----
t5form4.doca 03/06 System Pumping Record•Page 1 of 1