HomeMy WebLinkAboutSeptic Pumping Slip - 594 BOXFORD STREET 3/21/2016 Comm' Orw ealth Of Ma,,;sachusetts � �n
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system Pumping Record ���I�'I?
Form 4
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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 v,
local Board of Health to determine the form they use. The System Pumping Record must be subn
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A- Faci iii Wormatiion
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab }
key to move your Address
cursor-do not North Andover
use the return
key. City/Town
State, Zip Code
2. System Owner:
hk n 5e n
Name _-
Address(if d'o`ferent from location) — "
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date...- - 2. Quantity Pumped:
G2llans
3. Type of system: ❑ Cesspool(s) Tank Se SIC
P` ❑ Tight Tank ❑ Grease Tr
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes N o
5. Condition of System:
__—CA
6. System Pump y:
Name
Vehicle License Number —
Stewart's Septic Service
Campany —..._.....
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature o`Hauler
Date
Stgnature 7of Receiving Facilry
Date
i5form4.doc-03/06
System Pumping Record-Page