HomeMy WebLinkAboutSeptic Pumping Slip - 37 WHITE BIRCH LANE 5/12/2016 RECOVED
Comm' onweafth OF Massachusetts
H1 '
City/T own of Nb�h Andover /111( V! l(M)
VV�4 OF '0fl 11 AJU()''FR
SYstem PumOrig Record
Forra 4
DEP has provided this form for use by local Boards of Health. Other forms s may be used, but Ih
information must be substantially the same as that provided here. Be-Tore using this form, checl
local Board of Health to determine the form they use. The Sys-Lem 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 Wormation
Important:When
1911ing out loans 1. System Location-,
on the COmput ter,
use only the tab 7(AAlt
key'to move your Address
cursor-donot
use the return North Andover
key,
Zip Code
Z System Owner:
A
Name --------
Address(if Fdiffeent different from
7City/T,�own -
State Zip Code
Telephone Number
B. Pumpilng Record
Date Yzz_//,_ * 151jl)
1. Date of Pumping ------ 2, Quantity Pumped:
GaHons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank Grease
❑ Other(describe):
4 Effluent Tee Filter present? ❑ Yes ❑ No 11 yes, was it cleaned? ❑ Yes 17 N(
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Stewart's Septic Service
Company
7 Location where contents were disposed:
.St warTs Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Date
_S_19_,at.re of
Receiving Facility -
ate
,,5fo-4.doc•03/06
SvStern Pumping Record-Pa