HomeMy WebLinkAboutSeptic Pumping Slip - 61 ABBOTT STREET 5/11/2016 Commonwealth of Massachusetts
v City/Town of Nbrtth Andover
System Pumping Record c.//V
Form 4
Ft.t"�f t•
DEP has provided this form for use by local Boards of Health, Other N be used, but the
information must be substantially the same as that provided here. Before using this form, check wit
local Board of Health to determine the form they use. The System Pumping Record must be submi
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
Suing 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. City/Town _. --- —
State Zip Code
2. System Owner: e, r,
---- - _.
Name _.....__ .._........ ......__. _._..__._
Address(if different from location]
State Zip Code
City/T own
Telephone Number
B. Pumping Record
1. Date of Pumping date ' - -- - -- `""Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) /'Septic Tank ❑ Tight Tank
❑ Grease Tra
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes
❑ No
5. Condition of System:
---- ---
6. System Pump y.
ed B .,,,. .
Name ___-- - -- -- ----- --._... - -
—
Stewart's Septic Service Vehicle License Number
Company
?. 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 . ......_.._ _.
,5form4.doc-03/06
System Pumping Record-Page