HomeMy WebLinkAboutSeptic Pumping Slip - 40 OXBOW CIRCLE 5/12/2016 Commonwealth Of Massachusetts r " ENED
Ci Y/Ores of North Andover
TS um ing Record
Form 4
DEP has provided this form far use by local Boards of ueakth. Other forms 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 sL
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
Important:when
Niling out forms 1. System Location:
on the computer,
use only the tab "
key to move your Address C ..._.,----.•-.----
_. ...____._...._...._... . ... __.._...-._._--
cursor-d o n ot North Andover
use the return
key. C'ryfTown -°-
State, zip Code
2. System Owner:
Name
Address(if drf`erent from location} — ' "'"-......._ .....
C tyrown •---_._. .. ..............
Stzte Zip Code
Telephone Number
Pumping record
1. Date of Pumping
Date 2. Quantity Pumped:
lions
3. Type of system: ❑ Cesspool(s) [� Septic Tank ❑ Tight Tank ❑ Grease
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No It yes, was it cleaned.
17 Yes ❑ N
5. Condition of System:
6- 1,(V
6. System Pumpe „By
Name --------•--- --- —--..—.- ------...--—•---
_Stewart's Septic Service Vehicle License Number
Company _..._ . .,......
7. Location where contents were disposed:
St wail's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Date
Signature of Receiving Facilry
Dzte ....,._._
,,5' -03/x6
System Pumping Record-Pa