HomeMy WebLinkAboutSeptic Pumping Slip - 43 VEST WAY 6/29/2016 Commonwealth Of [Vlassachusetts
CRY/Town of North Andover
RECEIVED
.system Pumping
Form 4 �w1
DEP has provided this form for use by local Boards olt�t&CIF-Ir al'r�a
information must be substantially the same as Thai provided here Before using b sUOem,tcheck
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. Faci my worl-mation
importani:•When
511ing ou corms 1. System Locatio,
on the computer,
use only the tab �y %
key to move your Address
cursor-do not
use the return North Andover
key. City/Town ......... ........ _
State Zip Code
2. System Owner:
J
Name
Address(if deferent from location).--...... ..
Citty/T own
State Zip Code
B. pump'i ' Telephone Number -
1. Date of Pumping p �
e... ---....... .......... 2. Quantify Dumped: ( t_.J
gallons
3. Type of system: ❑ Cesspool(s) [1 Septic Tank ❑ Tank Tight 9 ❑ Grease•
❑ Other(describe): - .....__._...._...._..._.. _-.---_..__.__....._.
4. Effluent Tee Filter present? ❑ Yes [
If yes, was ii cleaned? El Yes ❑ No
S. Condition of System,:
6,
6. System- �u _._
ped By: /.
Name``~-..
Vehicle License Number
Stewar%'s Septic Service
Company �.._._..._..... ,......_ .
T Location where contents were disposed:
Ste wart's Pre-treatment Plant 20 So, Mill Bradford, Ma 01835
%-
5ignatu e o`
Date
Signature of Receiving Facility
Dzte ....._.._
25form4.doc•03/06
System Pumoino Record-par