HomeMy WebLinkAboutSeptic Pumping Slip - 1560 SALEM STREET 6/23/2016 City/Town Of North Andover
.System Pumping record �m) F
Form 4 EAW: ��Iwo :��6ww �:lii
DEP has provided this form for use by local Boards of Heal""-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. Facliky Wormation
Important:When
ailing ou corms 1. System Location:
on the computer,
use only the tab AS l / ❑
key to move your Address _._.._...._.._–°•--•---.__.. ...__..__._....,_...._... - .
cursor-do not
use the return North Andover
key. City/Town _.....
.,__........_ ..,... _
State Zip Code
2. System Owner-
T
Name
Address(if difFerent from oc2tion
i )
City/T own __ _...,....... ..... ..
State Zip Code
Telephone Number
B. Pumping Record
� K~ Pum u
1. Date of Pumping rD /
Date 2. Quantity pad.
aeons
3. Type of s stem:
Yp Y ❑ Cesspool(s) "Septic Tank ❑ Tight Tank ❑ Grease
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Na !f yes, was ii cleaned? ❑ Yes Nc
5. Condition of System:
/T
( „'r- t r
6. System Pumped(By
T.. a
Vehicle License Number —
Stewart's Septic Service
Company —..._..... ......._ .
7. Location where contents were disposed:
StewarTs Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Sa gnature os Hauler
.._.-------
Signature of Receiving Facil"ty - °`"
Date
k5form4.doc-03/06
System Pumpinq Record-Pa.