HomeMy WebLinkAboutSeptic Pumping Slip - 175 STONECLEAVE ROAD 5/25/2016 Commonwealth of Ma,,�sachusetts RECFEIVE,7-D
Cityl1-Orwn of North Andover
HEALTH Z)EPAj�
Form 4
DEP has provided this form for use by local Boards of `ieaith. Other forms may 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 lnlormation
Important:When
fining out forms 1. System Location:
on the computer,
use only'he tabs
key to move your Address —
cursor- not North Andover
use the return
key. C'ity/Town _._........ ... ....
2. System Owner: State Zip Code
i
Name `—" — —__. ._. ...._ .._....,...
Address(if different from location)
State Zip Cade
Telephone Number
�. Pumping Record
' -
1. Date of Pumping
Date �... ,
2. Quantity Pumped: —_
Canons
3. Type of system: ❑ Cesspool(s) EA tic Tanl<
p ❑ Tight Tank ❑ Grease Tra
D Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? Y
❑ es ❑ No
5. Condition of System.
6 System Pumped .e, ..��.�.
_...._ Name
Stewart Service IV
—
�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 Facil'ry
Date --
t5form4.doc-03/06
System Pumping Record•Page i