HomeMy WebLinkAboutSeptic Pumping Slip - 975 FOREST STREET 6/3/2016 Commonwealth Of Massachusetts RECEIVED
System. Pumping Record
`Y s Orm 4 u OW4 OF NORTH A,,IDOVE
DEP has provided this form for use by local Boards at Heai":h. Other forms may be used, but
information must be substantially the same as that provided here. Before using this form, chi
local Board of Health to determine the form they use. The System Pumping Record must be
the local Board of Health or other approving authority within 14 days from the pumping date i
accordance with 310 CMR 15.351.
A. FacHity Information
Important:When
51iIng out foms 1. System Location:
on'he computer, „
use only the tab
key to move your Address
cursor-do not North Andover
use the return
key.
`State Zip Code
2. System Owner:
Name _—---_._.—.._..
Address(if different from location) -
CPty/i own — -_
........ .... ar`late ._._.�,.-
Zip Code
Telephone Number
�. Pumping Record
7. Date of Pumping -. .- --.__g__. .. ...._
1
Date 2. Quantify Pumped.
Gallons
3. Type of system: ❑ Cesspool(s) ❑"Septic Tank ❑ Tight Tank ❑ Gr ea,
❑ Other(describe): — - ....._.-........__.. _.•._..__ - _ ..__._....... .
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it deane-d? ❑ Yes ❑I
5. Condition of S stem:
6. System Pumped By:
– —
Siewart's Septic Service Vehicle License Number
Company _..._.....
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
µ.
gnature a„;„Hau
Date _.. ---_—
Signal Rece �
... ... .. . ....... . _.:m . ..
�FacilPy
Date
t5'0rm4.doc-03/06