HomeMy WebLinkAboutSeptic Pumping Slip - 267 OLD CART WAY 6/2/2016 ��X
RECEIVED
Commonwealth Of Massachusetts
9 City/Town Of NarLh Andover
System Pumping Record tq oppi���
Form 4
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 wii
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.
Important:When
fining outforms 1. System Location:
on the computer,
the to
use only the tab
key to move your Address
cursor-do not
use the return North Andover
key. Ci`iy/Town —.—.._---.-._.._........
Stag Zip Code
2. System Owner:
Y aaf
Name
ieron
......................_ ....-.
Address(if different from Location_)._.
City/T own --._-.__.-. .._........ .... .., _...- -...._.._..__.—._..... _
State Zip Code
Telephone Number
Pumping Record
1. Date of Pumping - z.4_ `❑ ..._......
Date 2. Quantity Pumped: --
Gal on
3. Type of system: ❑ Cesspool(s) E 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 Pumped By:
Stewart's Septic Service Vehicle License Number
Company —..._.... .
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
ignatur a er — - -...--..... _.....
' date
g f Receivix+ Facility
Date,_...._.... ..._._._.__... .. _
i natur o NM�
k5form4.doc•03/06
System Pumping Record-Page