HomeMy WebLinkAboutSeptic Pumping Slip - 369 SALEM STREET 5/12/2016 Commonwealth of Massachusetts
�. C' Y/own of North Andover
tern Pumping Record
i orm.4
DEP has provided this Corm for use by local Boards of Health. Other forms may be used, but to
information must be substantially the same as that provided here. Before using this form, 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.
A. Facility Information I n�fj
Important_When e
filling out forms 1. System Location:
on the computer,
usonly the tab y c- (>I �� �..� � �"t�l?�I U ll Y�o( f III (��df➢�;:VER
key to move our Address /
cursor-do not North Andover
use the return '
key. City/Town
State, Zip Code
2, System Owner:
r�
'�Name V
:. --__..`.._.. .._......_
Address(if different from location)
. State Zip Code
Telephone Number
PUMPing record
1. Date of Pumping -•--... _._. _
Date - 2 Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease
❑ Other(describe): —•-----=....:.,._-___..-_-.._.._..�.___-.___._.._..
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ Nc
5. Condition of System: ,
d❑., �
6. System Pumped By
Stewart's Septic Service
vehicle License Number -----
Company _,.._.....
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature
Date
Signature of Receiv ng Facility
Date _
,5form4.doc•03/06
System Pumping Record-P<