HomeMy WebLinkAboutSeptic Pumping Slip - 51 BANNAN DRIVE 8/29/2016 Commonwealth Of Massachusetts
CRY/I own of North Andover
System PumpEng Record
Form 4
DEP has provided this form for use by local Boards of Health. Other l'Orms may be used, but
information must be substantially the same as that provided here. Before using this form, chE
local Board of Health to determine the form they use. The System Pumping Record must be
the local Board of Health or other approving authority within 14 days from the Pumping date i
accordance with 310 CMR 15.351.
A. Facility Informa
Important'When
,711'Ing out Toms 1. System Location:
on the computer,
use only the tab
key to move your _Address ------
cursor-do nolk
use'the retum North Andover
key, cit,ylTown Z.jP Coo:a—
2 System Owner:
Name
Address(if d Nrent from location)
State Zip
D B. Pumping Rec.ord Telephone Number
c3(
Le i
o , 1. Date of Pumping 2. Quantity Purnped
I G Date
Gallons
TOWN OF NORTI P AP40OVER 3. Type of system: 13 Cesspool(s) ❑ 'Septic Tank ❑ Tight Tank El Grea-z
riEPJ_T�
❑ Other(describe);
4. Effluent Tee Filter present? ❑ Yes D-'Klo If yes, was it cleaned? Yes
5. Condition of System:
6. -System?Omped By,-
Name
Vehicle License Number
w2rt's Septic Service
Company
7. Location where contents were disposed:
StewartAfr'_treatment Plant, 20 So. Mill Bradford, Ma 01835
""'"'Signature of Hauier
Date
Signature of Re
Date
t5'5' CM4.doc-03/06