HomeMy WebLinkAboutSeptic Pumping Slip - 106 ROCKY BROOK ROAD 5/4/2016 Commonwealth Of Massachusetts
— -- r City[Tow a Of north Andover
System Pump�ng Record
Form 4 (t
DEP has provided this form for use b local Boards of Health. Othe a " 7
Y `,91 but the
information must be substantially the same as that provided here. Before using this rm, check with
local Board of Health to determine the form they use. The System Pumping Record must be submiae
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 tab '
key to move your Address - -----------.
cursor-do not North Andover
use the return -- --"_.._...
key. ity/Town
y' State Zip Code
2. System Owner: U r
Name
Address(if different from location)
City/Town __--._._.._..__-_.—..._._.._..
State Zip Code
- 'telephone Number -. -----------
B. Pumping Record
1. Date of Pumping aai 2. Quantity Pumped: ---
Gallons
3. Type of system: ❑ Cesspool(s) Septic 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:
6. System
Pumped By:
StewarYs Sep rvlce -- - — -. —
am tiC Sen.� ..�.,�_,�,�,_..,..,�,__,,.�..-_.,... _ 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 - .."._..
Doke ......_.._.
t5form4.doc-03/06
System Pumping Record•Page 1 o