HomeMy WebLinkAboutSeptic Pumping Slip - 67 SHERWOOD DRIVE 7/21/2016 Commonwealth Of Massach sett
City/Town of A/0
_ t win i n Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
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 Information
Important:When
filling out forms 1. System Location:
on the computer, �7
use only the tab
key to move your Ad res
cursor-do not � .
use the return - - -- —
key City[Town State Zip Code
� r
` 2. System Owner:-,,,-
Name - ----- - -
etmn
7a0iF 1'Ir?(.'1�/C }'t
Address if different from location
City/Town State Zip Code
Telephone Number
B. Pumping ec®rd -- -
1. Date of Pumping Date-... ._ 2. Quantity Pumped: Gallons - -
3. Type of system: ❑ Cesspool(s) n/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System mped By:
MR Vehicle License Number
Ste I wai t's Se tic Service
C2frapany
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc^03/06 System Pumping Record •Page 1 of 1
Commonwealth of Massachusetts
City/Town Of No Andover
w Pumping �y r r �
,
^A'
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
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 Information
Important:When
filling out forms 1. System Location: ,,. _
on the computer, +
use only the tab -- _.. � l _ I.....
key to move your Address
cursor-do not No Andover Ma
use the return - -- ------- —---
key. City/Town State Zip Code
2. System Owner:
ray •�..,
Name
retwn
Address(if different from location)
-- - - - ---------------- -
City/Town State Zip Code
Telephone Number
B. Pumping ec r
1. Date of Pumping Date - 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ] Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --- -
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
P
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service - -
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01635 --------
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record.Page 1 of 1
_LN Commonwealth of Massachusetts
City/Town oo. Andover
f >
/
a f N Ad px I'
l
System Pumping Record idl'Y
Form 4
Hf /il ff6 [1('i
DEP has provided this form for use by local Boards of Health. Other forms ay° rused; bu
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
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 Informati®n
Important:When
p` Looation:
on the e come tab' 1. St m
filling y , a
key to move your Address a
cursor-do not No. Andover Ma
use the return City/ - -----------------
- -----------
key. City/Town State Zip Code
2. System Owner:
.N
W.,
--- =
Name
ietum �A
---------------- —— --
Address(if different from location)
------ ------------ --------------------------- -------------
City/Town State Zip Code
-------- -------------
Telephone Number
B. Pumping Record
f
1. Date of Pumping 2. Quantity Pumped: — —
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- - - ---
4. Effluent Tee Filter present? ❑ Yes F o If yes, was it cleaned? ❑ Ye o
5. Condition of System:
6. Sys to Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Bradford, Ma 01835
NRecei ent Plant, 20 So. Mill Stewart sere-treatm Signature Date Signature cility Date
t5form4.doc•03/06 System Pumping Record •Page 1 of 1
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System Pumping Record page 1 of I
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