HomeMy WebLinkAboutSeptic Pumping Slip - 41 CHERISE CIRCLE 6/29/2016 RECEIVED
Commonwealth Of Massachusefts
Y n ol North Andover JUH
_
System. Pumping Record 'O '� :l��rlarti•,,... ,
4 4(
�-Orm 4 Lf'
DEP has provided this form for use by local Boards of I-iealih, Other forms may be used, but th(
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 bumping 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 Wormatiio»
Important:'When
I
ining out Toms 1. System Location:
on the computer,
use only the tab
key to move your 0.ddress � ' --...
cursor- not North Andover
use the retet urn
— — —.
key. G'tty/Town .._.._.......... .
'State Zip Code
2. System Owner:
Name =-- —..__
Address(if different from location)
State Zip Code
Telephone Number _.._.._.__.__.
Pumping Record
1. Date of Pumping _.�?.. ... ...1.- ? ❑❑
Date ,.;_.Quanilty Pumped: Ca tons
3. Type of system: ❑ Cesspool(s) Septic T ank ❑ ?i ht Tank
9 Grease'
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes €�o If yes, was it cleaned? ❑ Yes El No
5. Condition of System:
6. System-P mped By:
me G E .,..
Ste wart's Septic Service Vehicle License Number
Company _.....
7• Location where contents were disposed:
Sie---w _F' e-treatment Pf SO, Mill Bradford Ma 01835
Signature of H9,oTer
Date
Signature of Receiving Facil'ry
45form4.doc-03/06
System Pumoine Record.Per