HomeMy WebLinkAboutSeptic Pumping Slip - 26 STANTON WAY 6/9/2016 Com RECEIVED
YSte "9 Pumping Record T u1�O�-�V)��TH A,1 [)OVER
Form�4 HEALIi�l DE[ �P�1 Iw�.VV.i. �
DEP has provided this form for use by local Boards of Heal;h, Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check wit
focal 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 Wormation
important.When
filling outforms 1. System Location:
on the use only' e to br
— C" ----
keyta move our Address `/ ..__..----•.---..._..
cursor-do not -
use he return North Andover
key. Crty/Town
_... State a .. Zip Code
2. System Owner;.,
Name
Address(if different from location) _
City/T own - °- —._.... - -—•
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
�a r 2. Quantit y Pumped' G
Date----- __. .... .... . p dons --
3. Type of system: ❑ Cesspool(s) ❑peptic Tank ❑ Tight Tank ❑ Grease Tra
❑ Other(describe): - ....... .......__..__..._..---- - - -
4. Effluent Tee Filter present? ❑ Yes Q-No Ii yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6. I-Sysmped S y�
Name — Vehicle License Number -
Stewart's Septic Service
Company _..._..... ..,..._ .
7. Location where contents were disposed;
Stewart's Pre-r atment Plant 20 So. Mill Bradford, Ma 01835
Signature of Hauler --- --
--__....._ Date
Signature of Receiving Facil'ry _
Date -
t5fom4.doc-03/06
System Pumping Record-Page