HomeMy WebLinkAboutSeptic Pumping Slip - 110 FOREST STREET 5/27/2016 Commonwean of Massachusetts /?ecelvcj)
City/Town of Nbrth Andover J�,//v
System u �n �� � J � l 1
Form 4
, NDO
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 wi
local Board of Health to determine the form they use. The System Pumping Record must be subm
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351,
A. Facifty Wormation
important:When
n1ling out forms 1. System Location: .
on the computer,
P .
use only'he tab
key to move your Address �-
cursor-do not North use the return And —,___--
key.
y State Zip Code
G
2. System Owner: ?1
Name
Address(if different from location) .. ..._...._. ,__._._....-•------..._.._._----_-._—.___--
City/T own _..-°- -._..,. —.—.......
State Zip Code
Telephone Number
�. Pumping Record
7 1• Date of Pumping
Date - - -_ ... _. 2 Quantity Pumped:
a lions
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Try
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes a No If yes, was it cleaned? ❑ Yes ❑ Pao
5. Condit' of Sys+-m:
6.
Ste
N �
_Stewari's Septic Service Vehicle License Number
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
t5fom4.doc•03/06
System Pumping Record•Page