HomeMy WebLinkAboutSeptic Pumping Slip - 796 WINTER STREET 5/12/2016 -`� Commonwealth Of Massachusetts
own of North Andover
SYStem mp"Eng Record
Form 4
DEP has provided this form for use by local Boards of Heal,,h. Other forms may be used, but in
information must be substantially the same as that provided here. Before using this form, checi
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. Facifity it or '7
Important:When
filling out loans 1. System (vocation:
the 'he t ab
computer,
use Address
use only y the t � (c^• B�"��°yr" .�,��°""...
key to move your _._.._ .
cursor-do not
use the return North Andover
key. C'rtylTown -----
State,, Zip Code
2. System Owner:
<1: _
Name -- .—.._.. ._.....__._.
Address(if dfferent from location) -
Cityrown --__.-. .._........... ...
State ..._ Z'_i Code
Telephone Number
. Pumping Record
/_ a
1. Date of Pumping --- ..:. ;7.._..
pate 2. Quantity Pumped;
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank L-1 Grease
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ N
5. Condition of System:
6. System Pumpe
.d By .� >
Name ---- —
Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Ste art's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
Signature o,Hauler
Date
Signature of Receiving Facility ...... -
2 to
C6torm4,doc-03/06
System Pumping Record-P�