HomeMy WebLinkAboutSeptic Pumping Slip - 195 FARNUM STREET 6/24/2016 Commonwealth Of Ma�sashusetts
City/Town of NbrLLh Andover
d Ystem Pumpang Record
Form 4
JUL
).
DEP has provided this form for use by local Boards of Health. OIOWN U" I40RII l l bu!the
information must be substantially the same as that provided here. �eroreu sg horn, 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.
�. Faciiity ill�fo�mafion
Important:When
filling outforms 1. System Location:
on the computer,
use only the tab "a �'� '�
key b move your Address
cursor-do not North Andover
use the return
key. City/Town --_—_-..._.._..........
Sate - Zip Code -
2. System Owner.
� Cm.
Name _ -- -_._-__ ._..
Address(if different from location) -
City/T own ---._. ..._......... ...
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - ti ` ._�._� ...- sod
Date Quantity Pumped: 'Ga on�s
3. Type of system: ❑ Cesspool(s) Septic Tank
p` ❑ ight Tank ❑ Grease T ra
❑ Other(describe): - - .. ..-,-.......__..._..._..—. - - -
4. Effluent Tee Filter present? ❑ Yes P--No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By: - _._...._
t
Name le_
icense
Vehic L Number
SteWart'S Segi1C Service
Company _..._.....
7. Location where contents were disposed:
e-W- re-treat Plant, 20 So, Mill Bradford, Ma signature of of H # r ._._ _...,.
Date___ .
_— _-___--- -- .._. .. ...
Signature of Receiving FacilPiy - '
t3form4.doc•03/06
system Pumping Record-Page i