HomeMy WebLinkAboutSeptic Pumping Slip - 115 CRICKET LANE 5/12/2016 Commonwealth Of Mca,�SaChusetts
= ❑—fOres of Nbilth Ando eeF
Pumping Record
Form 4
DEP has provided this form for use by local Boards of Heal�.h. Other forms may be used, bui th
information must be substantially the same as that provided here. Before using this farm, checl
local Board of Health to determine the form they use. The System Pumping Record must be sL
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
Important When .�
filling out forms 1- System Location:
use the computer,pe ttab 1�
use only the tab !.;,.
key to move your
, f�� G .Address
cursor-do not - -----.._.�_use the return North Andover
key. City/Town — —..... ........... .
State. Zip Code
r�
2. System Owner;
Address(if d'iff'erent from location)•
State Zio Code—
Telephone Number
Pumping Record
1. Date of Pumping Date - - Pumped: - I
..
2. Quantity
capons
3. Type of system: ❑ Cesspool(s) Sepik Tank ❑ Tight Tank ❑ Grease
❑ Other(describe): — _...__.._.._.. - — ..._.._..
4. Effluent Tee Filter present? ❑ Yes ❑ No If ves, was it cleaned? ❑ Yes ❑ N
5. Condition of System:
6. System Pumped By:
_Stewart's Septic Service Vehicle License Number
C ompany —..._.....
T. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
Signature of Hauler --- - ---
-
Signature of Receiving Facili y
Date
,5'orr-,4.doc-03/06
System Pumping Record-Ps