HomeMy WebLinkAboutSeptic Pumping Slip - 43 CHRISTIAN WAY 6/2/2016 Commonwealth of Ma,,�sachusetts
RECEIVED
City/Town of Nbr-th Andover
° system Pumping Record '[OWN O I'4D°VIrAV1C•1C'iVI Ff
` Form 4 HEAllfi DUVIK�OLN�[
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 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. FacHity Worrmatio n
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. Stage Zip Code
2. System Owner
Name
Address(if different from location}
State Zip Code
Telephone Number
B. Pumping Record -
1. Date of Pum in '
P 9 Date - - ----. � _ ... .- 2 Quantity Pumped: - --
Gallons
3. Type of system: ❑ Cesspool(s) 2 5eptic Tank ❑ Tight Tank ❑ Grease Tra
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S stem:
------------�cn J ------- -------
6. System Pumped By:
Name ---------.—,_..... .. _ ..—._._ •-- ------- _
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
w
nature IN -- - --....__
- Date
Signature of
r Y Date
t5'orm4.doc•03/08
System Pumping Record-Pagc 1