HomeMy WebLinkAboutSeptic Pumping Slip - 93 CRICKET LANE 8/29/2016 commonwealth 0-IF Massachusetts
I ON FLN! City/I—own of North Andover
System Pumping Record
Vorm 4
DEP has provided this form for use by local Boards of Heal"-h. Other forris may be used,
information must be substantially the same as that provided here. Before using this form
local Board oflHealth to determine the form they use. The System Pumping Record must!
the local Board of Health or other approving authority within 14 days from the pumping da-
accordance with 310 CMR 15,351.
A- Facility lnform� ion
Importan't'When
fililing outforms 1. System Location:
on'the c6mpLr'er,
use only'the ab
key to move your AAdd, s
cursor-do not
use the return North Andover
C'rtyrown `acetate � —P Coax
2, System Qweer,
Name
Address(if d'�eren,,from-location)'--
ZF,;/�r�O_r -
_�'Z.ate
Zio Code
.CEIVED Telephone Number
PUM ping Record
"J'A"
1 Date of Pumping 2, Quantity Purnpedi
rOW14 U H AW-OVEER4 Date Gallons
3. Type of system ❑ cesspool(s) I/Septic Tank ❑ Tight Tank ❑ Gri
❑ Other(describe).- .........
4. Effluent Tee Filter present? ❑ Yes No X
i yes, was it cleaned? ❑ Yes
5. Condition oafys,em,
S. System Pumped By:
Name
Stewartt's Septic ,Service Vehicle License Number
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01836
Signature of Hauler
Date
Signature I le
Date
k5fQr`-`R4.doc-03106