HomeMy WebLinkAboutSeptic Pumping Slip - 45 LIBERTY STREET 5/12/2016 Comm' Onwealth Of Massachusetts r 'r,,,,rz
Ci Y/I own Of North Andover ; I,,
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TK stem Pumping record
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Form 4
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 CM 15.351.
A. Faci ilty Wormalfion
Important:When
Fling out forms 1. System Location:
on the computer,
use only the b (y)("f ,f&",
key to move your Address -- - — ___..-.----- -.__..__._..---•----.
cursor-do not North Andover
use the return
key. CityfTown
State Zip Code
2. System Owner.
Name -
rew;i
.Address(if dfferentfromlocation) - - -- ••- _._.___...._.___,_.__...__,___.______—,__
Cityrown _..,. — - — —.—......__._..
State Zp Code
Telephone Number
B- PUMPiulg Record
1. Date of Pumping Gate / - �- -•. _....._... 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Tr
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By
SteWari'S Septic Service Vehicle License Number
Company ._.—_.—.
T Location where contents were disposed:
St wart's Pre-treatment Plant, 20 So, Mill Bradford_Ma 01835
Signature of Mauler
Date
Signature of Receiving FaciIity
Dare
t5fom4,doc-03/06
System Pumping Record-Page