HomeMy WebLinkAboutSeptic Pumping Slip - 260 SUMMER STREET 5/4/2016 Commonwealth of Massachusetts
f� City/Town of No Andover ffi,
System pig Record
JON 0
Form 4
V CAF No
DEP has provided this form for use by local Boards of Health. Other forms ma gs VE--J`
information must be substantially the same as that provided here. Before using this form, c With your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
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 Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 260 Summer St
key to move your Address
cursor-do not No Andover Ma
use the return _
key.
City/Town State Zip Code
,n
2. System Owner:
Name
Tatum
- --------...___
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ecor
w. / .
1. Date of Pumping 2. Quantity Pumped: ----
Date Gallons
3. Type of system: ❑ Cesspool(s) D(eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: I
6. s'fe
y m Pum fed 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
Signature of Hauler Date
....__------ __ - - - _. .. __.....- -
Signature of Receiving Facility Date
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