HomeMy WebLinkAboutSeptic Pumping Slip - 50 CHRISTIAN WAY 5/12/2016 Commonwealth
of Massachusetts """'W', D
City[Town of No' r-Lh Andover
System Pumping Record pj
Form 4 IUNI'1(1� �J:�ATIAI�DOVSII'
DEP has provided this form for use by local Boards of Health. Other Corms may be used, but the
information must be substantially the same as 'that provided here. Bel-Ore using this form, check\A
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 CMR 15.351.
A. Facility Wormation
Important:When
filling out forms 1 System Location:
on the computer,
use only the'Lab
tc
key to move your Address ------—
cursor-do not
use the return North Andover
key. Cfty/Town
State,, Zip Code
2. System Owner,
Name
-Address(if�different from�-Fo�uo�)'— -------
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s)
❑ ight Tank El Grease Tr
Septic Tank
❑ Other(describe):
4• Effluent Tee Filter present? ❑ yes ❑ No i yes, was it cleaned? El Yes El No
5. Condition of System:
6. 'System Pumped By:
Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed,
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Si of�Haule,��—'--- ----------- -D,-a',-e"--
ig�nature Tof Receiving cctji�, -- Date
t5fOrm4.doc•03/06
System Pumping Record-Page