HomeMy WebLinkAboutSeptic Pumping Slip - 280 GRANVILLE LANE 3/17/2016 I
Commonwealth of Massachusetts
City/Town of No. 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 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 1. System Location:
forms on the
computer,use 280 Gra&ville Lane
only the tab key Address
to move your No.Andover Ma r __ 01845
cursor-do not CitylTown State Le
gD
use the return
key, 2. System Owner:
.i r r
IVA Paradise Oil
Name 70WN OF NORTH ANDOVER
tE
rermn Address(if different from location) "®�
City/Town State Zip Code
Telephone Number
B. Pumping Record ��00
1. Date of Pumping Date 2• Quantity Pumped: 1G llons
3. Type of system: ❑ Cesspool(s) [ -S ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No j
5. Condition of System:
6. S tem Pumped By:
me Vehicle License Number
Stewart's Septic Service
Company
7, Location where contents were disposed:
Stew rt's Pre-tre t ent Plant, 20 So, Mill Bradford, Ma 01835
Signature of aul r Date �d /
Signature of R ce n F oil'y Date
I
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