HomeMy WebLinkAboutSeptic Pumping Slip - 250 ABBOTT STREET 6/6/2016 Commonwealth of Massachusetts
❑i'y/Town Of North Andover RECEIVED
° system Pumping record JUL Q F "N"N
`^ Form 4
TOWN OF NORTH 0,!XNEJ_.��
HEALTH D&Vk 11°0�Nr '
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. Facifiity Wormation
Important:When
suing out farms 1. System Location:
on the computer, __°��
use only'he tab �f
key to move your Address — __..._.---.--.. ...__.._---...--_-----. __ _ __
cursor-do not North Andover
use the return
key. C'ity/Town - -...._. ._....... ......._.. - ---
y State Zip Code -
vlkA2. System Owner: o
Name
---' "'_................_ ....
Address(if different from location) ."
City/T own _... -.._._.._.. —._.._..._-._..
State Zip Code
Telephone Number _.._..-.--._-•
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
—
allons
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. of System' �,.� .—
It Condition / �! �
6. Syste� `�nped By:
S
a 5
Name
License_Stewart's Septic Service Vehicle Lice Number
Company _..._....
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So, Mill Bradford, Ma 01835
Signature of Hauler D
--_, ..__..-._.....
' ate..
---- _
Signature of Re ceiving Facility "
Date
t5form4.doc-03/06
System Pumping Record-Page i