HomeMy WebLinkAboutSeptic Pumping Slip - 239 GRANVILLE LANE 6/17/2016 RECEIVED
Commonwealth Of Massachuse S
-h Andover
TC)WNOIF I�r)hxl'l_I✓+I � OVE:R
.System Pumping Record iIE 0L DEH),R, ILL�]
`Y c=orm 4
DEP has provided this form tar use by local Boards of alieal-h. Other forms may be used, but thf
information must be substantially the same as That provided here. Before using this form, check
local Board of Health to determine the form they use. The System Pumping Record must be su
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
511ing out farms 1. System Location:
on the computer, ry
use only'he tab
key to move your Address °�— " `– – _._.__,. .. __._
cursor-do not N ,
use the return North Andover
key. City/Town L
'State Zip Code
2. S stem Owner:
Name
Address(if d'rFFerentfrom location) .. _...._.. .__._--....__-----_....__._.__.---_-.._—•—
City/T own –.__._. .
State Zip Code
Telephone Number
B. Pumping Record
Date $
�
I. Date of Pumping w. ,' .�...'..��� I
to 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Se tic Tank
p ❑ Tight Tank ❑ Grease
❑ Other(describe): — .. ....__.......__..._... ..— -- — _
4. Effluent Tee Filter present? Yes
❑ NO If yes, was it cleaned? Lxyes ❑ Nc
5. Condition of System:
6. System Pumped By:
2
Name
Vehicle License Number
_Stewari's Septic Service
Company ---.._—
7. Location where contents were disposed:
St wart's Pr eta hment PI nt •20-. Mill Bradford, Ma 01835
Signa of u er
Date
Signature of Receiving Facili y -
Date
25forrn4.doc-03/06
System Pumpinq Record-Pa,