HomeMy WebLinkAboutSeptic Pumping Slip - 35 CHERISE CIRCLE 6/29/2016 Commonwealth of Ma_,�sachuset-s
r Cliy/Tow n Of North Andover RECEIVED
° . Y to Pumping Record
' Form 4
TOWN(IF N°0RTH FND y I:.I
DEP has provided this form i
for use by local Boards of Health. Other f �IorNmsL �t
may be but the
information must be substantially the same as that provided here. Before using this form, check wi'
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. Facility lnfo -motion
Important:When
filling out forms 1. System Location:
on the computer,
y� _ ( W ab
key to move your Address
cursor-do not North Andover
use the return
key. City/Town ---- —.._.._.......
State Zip Code
2. S Owner:
System
� v
Name
r�wn
Address(if different from location) _
I own State Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingM- "
2, Quantit Pum ed: alons
3. Type of system: ❑ Cesspool(s) [�"Septic Tank ❑ T Tank i ht
9 ❑ Grease Tra
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes es ❑ No
5. Condition of System:
.Y/
> ... �_-.
6. Syste P ed B
t
Name I
—
Stewart's Septic Service Vehicle License Number
Company —..._.....
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler -' °'°°' ---°
Date
Signature of Receiving Ii cil�,y
Date ._..._.._
i5fom4.doc•03/06
System Pumping Record.Page