HomeMy WebLinkAboutSeptic Pumping Slip - 793 SALEM STREET 5/12/2016 _ Commonwealth Of McaSs2C:huse s
-� C y/Own Of Nbr-Lh Andover
roping Record
Form 4
DEP has provided this Corm ;or use by local Boards of luleai;h, Other Corms may be used, but th
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 su
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 Wormat>ion 7171
Important.When
filling out forms 1. System Location: 1iA"J ��1
on the computer, ..,..
use only the tab
key'o move your Address -~ l I
cursor-do not
use the return North Andover
key. City/Town
State,. Zip Code
2. System Owner:
Name _. .__ .._ ... .. ... .__ .....--•----.._..---,_.___._—
Address(if d'ruerent from ocation
l )
................ ..
Sate Zip Code
TelephaneNumber
�. Pumping Record
rm..
1, Date Of Pumping 2. Quantity Pum ed:p 0 �cs)f;�
Gallo
3, Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease
❑ Other(describe): ---___ ....:...__..... _..__.._..
4. Effluent Tee Filter present? ❑ Yes ❑ No if cleaned.es, was it
y � ❑ Yes ❑ NG
5. Condition of System:
6. System Pumped By: '
Vehicle License Number
_Stewari's Septic Service
Company _,.._.....
7. Location where contents were disposed:
St wart's Pre-treatment Plant, 20 So. Mill Bradford_Ma 01835
Signature o`Hauler °-- ---
' Date
Signature of Receng Facilry
Date
t5f0rm4.doc-03/06
System Pumping Record-P<